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UNITED STATES OF AMERICA. 



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Plate I 



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Neevtxs LiporrLatocLes . 

(From a Photograph of one of the author's patients .) 
(Frontispiece .) 



A PRACTICAL TREATISE 



DISEASES OF THE SKIN, 



FOR THE USE OF STUDENTS AND PRACTITIONERS. 



THIRD EDITION, 
THOROUGHLY REVISED AND ENLARGED. 



BY 

JAMES NEVINS HYDE, A.M., M.D., 

PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST 

TO THE MICHAEL REESE HOSPITAL, CHICAGO; ONE OF THE PHYSICIANS FOR DISEASES OF THE 

SKIN TO THE PRESBYTERIAN HOSPITAL, CHICAGO ; AND CONSULTING DERMATOLOGIST TO 

THE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN. 




%ci ^ 1893 . 



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PHILADELPHIA: 

LEA BROTHERS & CO. 

1893. 



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Entered according to the Act of Congress, in the year 1893, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



BORN AN, Pit I NT£ 
PHILADELPHIA. 



TO 

MOKIZ KAPOSI, 

PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA, 

THESE PAGES ARE, WITH HIS GENEROUS CONSENT, 



ftegpeclfullg |nscribed 



BY 



THE AUTHOR. 



PREFACE TO THIRD EDITION 



The labor of preparing for the press a third edition of this treatise 
has been expended with a view to the correction and improvement of 
every page. The greatly increased attention to the subject of Derma- 
tology, influenced largely by the transactions of scientific bodies both 
in America and Europe whose work has been limited to the field of 
cutaneous medicine, and the numerous important publications devoted 
to the same theme in most of the modern languages of the civilized 
world, have rendered it difficult to secure for a text-book of this scope 
comprehensiveness and conciseness in an equal degree. 

Thirty-five new diseases are with greater of less fulness considered 
in the present edition. The chapter on Tuberculosis has been wholly 
rewritten and considerably enlarged, with a view to furnishing an 
exposition of this important subject from the point of view of modern 
bacteriology and histology. Lupus Vulgaris has been in that chapter 
properly relegated to a position among the verrucous and other cuta- 
neous manifestations of tubercle infection. Among other new and 
important chapters added may be named that on Pityriasis Rubra 
Pilaris, on Keratosis Follicularis, with several minor disorders tem- 
porarily considered in the same category, on Actinomycosis, on Leuco- 
keratosis Buccalis, on Xanthoma Diabeticorum, and on Pemphigus 
Vegetans. Among the several chapters of minor importance also 
added may be named those on Savill's Disease, on Scarlatiniform 
Erythema, on Acanthosis Nigricans, on Angioneurotic (Edema, on 
Acromegalia, on Alopecia Follicularis, on the Parasitic Forms of 
Eczema, on several varieties of Gangrene of the Skin, on some of the 
rarer diseases of the tropics, and on a few of those involving the hair 
and nails, both simple and parasitic. 

It has been found necessary, with a view to the needs of the prac- 
titioner and student, to still adhere in part to the classification of the 



VI PREFACE TO THIRD EDITION. 

American Dermatological Association. This has served as the ground- 
work for a variation demanded by the later advances in dermatology. 
For convenience, the coccogenous and bacillogenous dermatoses of 
inflammatory type have been here grouped together under a common 
heading. 

The new and original illustrations designed especially for this 
edition consist of five plates and twenty-two woodcuts. Of the 
latter, five represent careful drawings of sections of the skin, made 
under the author's special supervision. The colored and other draw- 
ings of cutaneous disease are reproduced either from paintings in oil 
or from photographs of clinical patients. 

The author has to express his special indebtedness to the valuable 
second edition of the work of his friend, Dr. H. Radcliffe Crocker, 
of London, which has appeared since these pages have been passing 
through the press ; also to the second edition of the practical and 
compendious treatise of Brocq, and to the current International Atlas 
of Rare Skin Diseases, which has become the important exchange 
for the dermatological experts of all nations. 

He is also greatly indebted for aid in proof-reading and indexing 
to his associate, Dr. Frank H. Montgomery, and to his assistant, 
Dr. W. F. Robinson. 

Chicago, September 1, 1893. 



PREFACE TO SECOND EDITION. 



The work of revision, required by exhaustion of the first and 
the demand for a second edition of this treatise, has been carefully 
conducted with results that are declared upon every page here pre- 
sented to the reader. There have been added new chapters devoted 
to the description of several cutaneous maladies whose names were 
a few years ago unknown ; others have been Avholly rewritten ; none 
has been left untouched. The need of conforming to the classi- 
fication and nomenclature of diseases of the skin adopted by the 
American Dermatological Association, has involved a labor which 
it is believed has largely added to the practical worth of the book. 
Personal observation of more than ten thousand cases of cutaneous 
disease in both public and private practice, has furnished an experi- 
ence which has been made to serve here as far as was practicable 
in the illumination of the teaching embodied in almost every para- 
graph. Nearly one hundred pages have thus been added, together 
with a number of new woodcuts and two portraits of rare diseases 
of the skin in colored plates. 

The author is anxious to express his sense of gratitude to the 
profession for the favorable reception accorded to the first edition 
of the treatise ; and desires to acknowledge his great obligation in 
the preparation of its successor, to the later authors especially, in 
cutaneous medicine, whose works are named in the brief but selected 
bibliography appended at the close of the volume. 

He has also to extend his thanks to Dr. Frederick W. Mercer, 
and to Dr. Albert J. Ochsner, of the Pathological Laboratory of the 
College, for aid in the preparation of specimens and drawings ; as 
also to his assistant, Dr. Frank H. Montgomery, for services rendered 
while the work has been passing through the press. 

Chicago, March, 1888. 



PREFACE TO FIRST EDITION. 



The increasing recognition of the gravity of many cutaneous dis- 
orders, and of the importance of their accurate study, is shown by 
the rapidly augmenting number of observers in this department of 
medicine, and by the numerous valuable contributions constantly 
made to it, both in this country and abroad. For the convenience ot 
the general practitioner it therefore becomes necessary at shortly 
recurring intervals that some one should attempt the task of pre- 
senting in a comprehensive form the results of the latest observation 
and experience. 

The author is aware of the degree to which he must claim indul- 
gence in the present effort to perform this duty. The extent of the 
subject and the limitations of a single volume require the omission 
of much detail of secondary importance. With regard to that which 
it has seemed proper to include, he has endeavored to write concisely, 
to set forth only what can be held as the truth, to be frank in the 
admission of the weakness with which the most skilful physician 
stands in the presence of many grave and not a few benign disorders, 
and to cultivate a wholesome doubt of that which has not been shown 
to be worthy of trust. How far he may have fallen short of attaining 
this end these pages will declare. 

He has to express his indebtedness to the standard works on 
dermatology of foreign authorship, especially to the exhaustive and 
invaluable work of Hebra, and to the Lectures on the Diseases of the 
Skin lately given to the profession by Professor Kaposi, which con- 
tain the mature conclusions of his vast experience. With these 
should be named the writings of Sir Erasmus Wilson, Dr. Tilburv 
Fox, Dr. Neumann, Dr. McCall Anderson, Dr. Behrend, and the 
syphilographers, to whose works special reference is made in the 
chapter devoted to their theme. Among the books of American 
authorship, he is under special obligation to the sterling work of Dr. 
Duhring, of Philadelphia, and to the excellent treatises of Drs. 
Piffard, Fox, and Bulkley, of New York. 

All these are named by title in the brief and selected bibliography 



X PREFACE TO FIRST EDITION. 

appended at the close of the volume. No less valuable aid has been 
obtained by consulting the papers of American and foreign authors 
contained in the journals specially devoted to diseases of the skin, 
among which, as the representatives of the English tongue, the 
Archives of Dermatology, lately edited by Dr. Bulkley, and the 
current Journal of Cutaneous and Venereal Diseases, edited by Drs. 
Piffard and Morrow, deserve special mention. 

The author is also very greatly indebted to Dr. Charles Heitzmann, 
of New York, not merely for the information gathered from the 
study of his original researches in pathology, but particularly for his 
kindness in furnishing advanced sheets of the chapter on the skin, in 
his work on Microscopic Morphology, which has just issued from the 
press. From this work, with Dr. Heitzmann's permission, several 
illustrations have been borrowed, which appear in the chapter on 
anatomy, the details of which subject are also very largely drawn 
from the same rich store. The first of the drawings representing 
sections of the skin is from the faithful pencil of Dr. H. D. Schmidt, 
of New Orleans, who, in order to produce it, interrupted, without 
hesitation, his arduous labors in connection with the subject of 
pathology. To his colleague, also, Dr. Frederick W. Mercer, of 
Chicago, the author is glad to express his indebtedness for the skill 
with which a number of pathological specimens have been prepared 
and mounted for special study, and original drawings produced for the 
first and several subsequent chapters of the book. To Dr. Duhring, 
of Philadelphia, he is further indebted for valuable suggestions made 
during the course of preparation of the manuscript. 

Medicinal measures are, in these pages, expressed in terms of both 
the apothecaries' scale and the metric system. It is to be noted, how- 
ever, that the latter are not in all cases literal translations of the 
terms of the former, many of the formulae, especially those for prepa- 
rations designed to be topically employed, being metrically composed, 
the relative proportions of the ingredients remaining unchanged. 

The changes which it has been advisable to make in the matter of 
nomenclature, classification, and other equally important subjects, are 
concisely explained in the chapters devoted to each. 

Chicago, No. 240 Wabash Avenue, 
February, 1883. 



CONTENTS 



PAGE 

Anatomy and physiology of the skin 17 

General symptomatology .52 

General etiology 64 

General diagnosis 70 

General prognosis 75 

General therapeutics 77 

Classification 96 



DISEASES OF THE SKIN. 

CLASS I. 
DISORDERS OF THE GLANDS. 

Of the Sweat Glaxds 101 

Hyperidrosis . 101 

Sudamen 105 

Miliary fever 106 

Anidrosis 107 

Bromidrosis 108 

Chromidrosis 109 

Uridrosis Ill 

Dysidrosis . . 112 

Hsematidrosis 112 

Of the Sebaceous Glaxds 113 

Seborrhcea 113 

Comedo 126 

Cyst 132 

(A.) Milium . . . . * 132 

(B.) Steatoma 134 

Asteatosis 136 

Congenital fibro-sebaceous disease 137 

Multiple dermoid cysts 137 

Consequences of sebaceous cystic disease . . . . 137 



Xll CONTENTS. 

CLASS II. 
INFLAMMATIONS. 

PAGE 

Exanthemata 138 

Morbilli (measles) 138 

Rotheln (German measles) 142 

Scarlatina (scarlet fever) . . 143 

Variola (smallpox) . . . 148 

Varioloid 152 

Varicella (chicken-pox) 155 

Vaccinia (cow-pox) . 157 

Erythema simplex 162 

Erythema scarlatiniforme 165 

Erythema intertrigo 166 

Erythema multiforme 169 

Urticaria 174 

Urticaria pigmentosa. ......... 176 

Angeio-neurotic oedema 177 

Dermatitis ............ 184 

(A.) Traumatica 185 

(B.) Venenata . 185 

(C.) Calorica 189 

Congelatio . . 190 

(D.) Medicamentosa 192 

Feigned eruptions 201 

(E.) Dermatitis gangrenosa 202 

Dermatitis gangrenosa infantum ..... 202 

Multiple gangrene in adults 203 

Spontaneous gangrene of eyelids 203 

Symmetrical gangrene ( Raynaud's disease) • . . 203 

Erysipelas 204 

The coccogenous and bacillogenous dermatoses . . . . 211 

(A.) Furunculus 211 

Hydroadenitis 212 

(B.) Anthrax 215 

(1) Simplex (carbuncle) 215 

(2) Maligna (malignant pustule) 218 

(C.) Equinia 220 

Pustules from cadaveric infection 222 

(D.) Delhi boil 223 

Phagedena tropica ........ 224 

(E.) Phlegmona diffusa 225 

(F.) Sycosis 226 

Dermatitis papillaris capillitii 232 

(G. Impetigo . . 234 

(H.) Impetigo contagiosa 236 

(I.) Ecthyma 238 



CONTENTS. Xlll 

PAGE 

Herpes 241 

Herpes iris 244 

Herpes gestationis 245 

Herpes zoster 246 

Dermatitis herpetiformis 253 

Pompholyx 255 

Psoriasis 257 

Pityriasis maculata et circinata 276 

Dermatitis exfoliativa 277 

Dermatitis exfoliativa infantum 280 

Pityriasis rubra 280 

Pityriasis rubra pilaris 284 

Epidemic exfoliative dermatitis 286 

Parakeratosis variegata 287 

Lichen ruber 288 

Lichen ruber acuminatus . 288 

Lichen ruber planus .......... 289 

Lichen planus as it exists in America 292 

Eczema 297 

The local varieties of eczema 340 

Eczema of the scalp 340 

Eczema of the face 343 

Eczema of the lips 345 

Eczema of the nostrils 346 

Eczema of the ears 347 

Eczema of the lids 349 

Eczema of the beard 350 

Eczema of the genital organs ....... 352 

Eczema of the anus and anal region 355 

Eczema of the nipple and breast of women .... 357 

Eczema of the umbilicus 358 

Eczema of the superior and inferior extremities . . . 359 

Eczema of the hands and feet 361 

Eczema as its affects the nails 364 

Eczema of the tropics (prickly, heat) 365 

Eczema, universal 367 

Eczema, parasitic forms of 367 

Dermatitis repens 367 

Prurigo . 368 

Acne 372 

Acne rosacea 384 

Acne varioliformis • 389 

Impetigo herpetiformis 391 

Pemphigus 392 

Pemphigus acutus 393 

Pemphigus chronicus 394 

Pemphigus foliaceus . 396 

Pemphigus neonatorum 397 



XIV CONTENTS. 

PAGE 

Pemphigus virginum 397 

Pemphigus vegetans . . . 398 

Hydroa 403 

CLASS III. 

HAEMORRHAGES. 

Cutaneous haemorrhages 404 

Purpura 405 

(A.) Simplex 405 

(B.) Rheumatica (peliosis rheumatica) 406 

(C.) Hemorrhagica (Werlhofii) 407 

(D.) Scorbutica (scurvy) 407 

(E.) Pulicosa . 408 

CLASS IV. 

HYPERTROPHIES. 

1. Of Pigment 411 

Lentigo 411 

Chloasma 412 

Uterinum 413 

Cachecticorum 413 

Addison's disease 414 

Argyria 414 

Arsenical . . . . 415 

Tattooing 415 

2. Of Epidermal and Papillary Layers 417 

Keratosis 417 

(A.) Pilaris 418 

(B.) Senilis 421 

(C.) Follicularis 421 

(D.) Palmaris et plantaris 423 

(E.) Angiokeratoma . 425 

(F.) Keratosis follicularis contagiosa 425 

(G.) Hyperkeratosis striata et follicularis .... 425 

(H.) Parakeratosis scutularis 426 

Molluscum epitheliale 426 

Callositas 432 

Of the hands with mutilation ....... 433 

Perforating ulcer of the foot 433 

Clavus 435 

Cornu cutaneum 436 

Verruca .... 439 

Multiple cutaneous tumors, pruritic 443 

Synovial lesions of the skin 444 

Papilloma 445 



CONTENTS. XV 

PAGE 

Nsevus pigmentosus 446 

Acanthosis nigricans 447 

Xerosis 448 

Ichthyosis 449 

Simplex 449 

Hystrix . 450 

Congenita 451 

Linguae 451 

Onychauxis 458 

Hypertrichosis 458 

3. Of Connective Tissue 464 

CEdema neonatorum 464 

Acute circumscribed cedema of the skin 465 

Sclerema neonatorum 467 

Scleroderma 468 

(A.) Diffuse symmetrical 468 

(B.) Circumscribed (Morphcea) 469 

Morvan's Disease . 475 

Elephantiasis 475 

Lymph scrotum 478 

Acromegaly 478 

Kosacea 482 

(A.) Erythematosa 482 

(B.) Hypertrophica 483 

Frambcesia 484 

Parangi 485 

Donda Ndugu 486 

Verruga Peruana 486 



CLASS V. 
ATEOPHIES. 

1. Of Pigment 487 

Leucoderma 487 

Albinismus 488 

Vitiligo 489 

Canities 492 

2. Of Hair . . 494 

Alopecia 494 

Congenital 495 

Senile 496 

Premature (pre-senile) 496 

Alopecia furfuracea 499 

Alopecia areata 501 

Neurotica 508 

Follicularis 508 



XVI CONTENTS. 

PAGE 

Atrophia pilorum propria 511 

Fragilitas crinium 511 

Trichorrexis nodosa 513 

Monilethrix 513 

Lepothrix ........... 514 

Piedra 515 

Beigel's Disease 515 

3. Of Nail 516 

Atrophia unguis 516 

Achromia unguium . . . 516 

4. Of Cutis 517 

Atrophia cutis 517 

Senilis 517 

Partial idiopathic 518 

Atrophia maculosa et striata 518 

Glossy skin 520 

Blanching atrophy of the skin 520 

Multiple benign tumor-like new growths 521 

Kraurosis vulvae ......... 521 



CLASS VI. 

NEW GKOWTHS. 

1. Of Connective Tissue 522 

Keloid 522 

Cicatrix 525 

Fibroma . 528 

Dermatolysis 531 

Neuroma 533 

Xanthoma 535 

Xanthoma diabeticorum 539 

Adenoma 541 

Colloid metamorphosis of the skin 542 

2. Of Muscular Tissue . . .543 

Myoma . . . . . . . . . . . .543 

3. Of Vessels 544 

Angioma 544 

Nsevus vasculosus ' 545 

Telangiectasis 546 

Angioma cavernosum 547 

Angioma serpiginosum ........ 550 

Lymphangiectasis 551 

Lymphangioma . 552 

Angioma pigmentosum et atrophicum 553 

4. 

Rhinoscleroma 556 



CONTENTS. XV11 

PAGE 

Tuberculosis cutis 558 

1. Lupus vulgaris 559 

Esthiomene 564 

2. Tuberculosis cutis verrucosa 564 

(A . ) Verruca necrogenica 564 

(B.) Other verrucous lesions 565 

(C.) Acne tuberculoses 566 

Ulerythema acneiforme 566 

3. Tuberculosis cutis orificialis 567 

4. Scrofuloderma 567 

Tuberculous dactylitis , 569 

Suppurative tubercular lymphangiectasis .... 569 

The dermatoses of the scrofulous 569 

Lichen scrofulosorum 570 

Small pustular scrofuloderm 570 

Large pustular scrofuloderm 571 

Lupus erythematosus 582 

Syphiloderma 591 

Chancre 593 

Syphiloderma maculosum 600 

Papulosum 604 

Yesiculosum ......... 610 

Pustulosum 610 

Bullosum 613 

Tuberculosum 614 

Tuberculosum serpiginosum ...... 614 

Gummatosum 616 

Ery than them a syphiliticum 617 

Syphilis of the mucous surfaces 618 

Syphiloderma infantile (acquisitum et haereditarium) . . 621 

Chancroid 644 

Lepra 649 

(A.) Tuberosa . .650 

(B.) Maculosa . . . . . . . . . . .653 

(C.) Ansesthetica 653 

The Sartian disease 662 

Pellagra 662 

Acrodynia : 664 

Carcinoma 665 

Epithelioma 665 

Superficial . m . . . Q65 

Deep (tubercular) 666 

Papillary 667 

Cancer of the head 670 

Cancer of the lower lip 670 

Cancer of the genital organs 670 

Cancer of the extremities 671 

Cancer of the mucous surfaces 671 

B 



XV11 1 



CONTENTS 



Paget's disease of the nipple 
Cancer of connective tissue 

Cancer en cuirasse 
Tuberose carcinoma . 
Melanotic carcinoma . 
Benign cystic epithelioma 
Leucokeratosis buccalis 
Sarcoma cutis .... 
(A.) Primary melanotic . 

" Melanotic whitlow " 
(B.) Primary non-melanotic 

Generalized melanotic 
"Recurrent fibroid of skin' 
Mycosis fungoides . 



PAGE 

672 
680 

680 
682 
682 
683 
683 
686 
686 
687 
687 
688 
689 
691 



CLASS VII. 

NEUROSES. 

Hyperesthesia 695 

(A.) Pruritus 695 

Pruritus narium 697 

Pruritus genitalium . 697 

Pruritus ani 697 

Pruritus palmae et plantse 697 

Pruritus hiemalis (winter itch) . . . . ... 703 

Prairie itch, etc. 704 

(B.) Dermatalgia 705 

Anaesthesia 706 

Vasomotor and trophic neuroses 707 

Myxcedema 709 



CLASS VIII. 



PARASITIC AFFECTIONS. 



1. 



Vegetable 712 

Tinea favosa 712 

Favus of the nail . 714 

Tinea trichophytina 720 

(A.) Tinea circinata 720 

Tinea trichophytina unguium 722 

(B.) Tinea tonsurans 727 

Tinea kerion 734 

Tinea sycosis 735 

Tinea imbricata 742 



CONTENTS. XIX 

PAGE 

Podelcoma 743 

Actinomycosis of the skin ........ 745 

Tinea versicolor 747 

Myringomycosis ......... 751 

Erythrasma 751 

La Perleche 753 

Pinta disease .......... 754 

Animal 754 

Scabies 754 

Demodex folliculorum . . . 765 

Pulex penetrans 765 

Pulex irritans ........... 766 

Filaria medinensis .......... 767 

Craw-craw 769 

Cysticercus cellulosae cutis 769 

Echinococcus 770 

Distoma hepaticum .......... 770 

Leptus ' 770 

Dipterous larvae in and beneath the human skin .... 772 

Ixodes (wood-tick) . . 773 

Pediculosis 774 

Pediculosis capillitii 774 

Pediculosis corporis 777 

Pediculosis pubis 780 

Vagabond's disease 782 

Pediculi and acari transferred to man from the lower animals . 782 

Cimex lectularius 782 

Other insects attacking the human skin ...... 784 

Culex pipiens, etc 784 



Bibliography 785 

Index 787 



LIST OF PLATES. 



Plate I. Nsevus Lipomatodes. (From a photograph of one of the 

author's patients) 

frontispiece. 

Plate II. Keloid Acne of the Back. (From a photograph of one of 

the author's patients.) 

facing page 374 

Plate III. Circumscribed Scleroderma. 

facing page 470 

Plate IV. Elephantiasis Telangiectodes of the Upper Lip and Por- 
tion of the Face. (From a photograph of one of the 

author's patients.) 

facing page 478 

Plate V. Multiple Fibromata of the Back. (From a photograph of 

one of the author's patients.) 

facing page 528 

Plate VI. Xanthoma of the Hands, Elbows, and Knees. (From a 
photograph of one of the author's patients.) 

facing page 536 

Plate VII. Lupus Hypertrophicus of the Face. (From a photograph 

of one of the author's patients.) 

facing page 562 

Plate VIII. Large Pustulo-crustaceous Syphiloderm of the Scalp 

and Body. (From a cachectic patient presented at 

the author's clinic. ) 

facing page 612 

Plate IX. Tubercular Syphiloderm, Resolutive and Serpiginous. 

(From a photograph of a hospital patient presented at 

the author's clinic.) 

facing page 614 



I. 

ANATOMY AND PHYSIOLOGY OF THE SKIN. 



The skin of the human body is its living envelope, intimately 
associated with underlying structures, and by its situation brought 
into intimate relation also with the external world. It is a complex, 
elastic, and sensitive organ, varying greatly in different conditions of 
climate, age, sex, health, and race ; and differing also in the charac- 
teristics exhibited in different localities upon the same individual. 
Thus, in color, there is a wide range between the fair skin of the 
blonde and the black of the negro, between the rosy pink of the 
infant's palm and the dark brown hue of the genital region of the 
aged. The skin varies also in pliability and thickness, being delicate 
and lax over the lids, the lips, and the prepuce ; and much thicker 
and more firmly attached over the palms and the soles. 

It is important to note that the appearance of the skin, even in 
conditions of health, also changes within appreciable limits. It is the 
exposed parts, such as the face, which the eye of the physician most 
frequently searches, and which betray evidence of mental emotions, 
physiological fluxes, sedentary or active habits of life, and fatigue or 
unusual conditions of vigor. 

Viewed externally, the skin is seen to be traversed by superficial 
and deeper furrows, dotted by numerous depressions representing the 
mouths of its follicles, and provided very generally with coarse or 
fine downy hairs which are in some parts represented by a growth 
sufficient to conceal the skin from view. This pilary growth serves 
not merely as an ornament of the body, but also as a protection to 
some of its regions most sensitive to thermal changes. 

By its extraordinary sensitiveness to different degrees of tempera- 
ture and to the physical properties of the bodies with which it is 
brought into contact, the skin becomes, even when unaided by the 
eye, a valuable means of preserving the human frame from external 
injury. This protective function is, in part, related to the horny 
character of its outer layer, as a consequence of which the loss of 
essential fluids and the ingress of noxious substances are equally 
restricted. 

One of the most important functions of the skin is the part which 
it plays in the regulation of the bodily temperature. The temperature 
variations at its surface, modified naturally by the character and 
quantity of the clothing, when such is worn, produce corresponding 
variations in the smooth muscles and contractile bloodvessels of the 



18 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

skin. By enlargement or diminution of the lumen of these vessels, 
whether resulting directly from the action of heat or cold at the 
surface, or indirectly through an effect upon the vasomotor centres, 
large quantities of blood are brought to or removed from the super- 
ficies of the body. In the one case, the blood is cooled by evaporation 
at the surface ; in the other, the loss of heat by such evaporation is 
greatly restricted. This process is materially influenced by accelera- 
tion or retardation of the heart's action, whether produced by moral 
or physical causes. It is also modified by the occurrence of sweating, 
as a result of which heat in varying amounts is rendered latent ; and 
either watery vapor escapes from the surface or sweat is exuded in 
drops, the aggregate of which may be several pounds in weight in 
the course of twenty-four hours. 

In a limited degree, the skin is capable of acting as a respiratory 
agent, eliminating carbonic acid gas with watery vapor, and possibly 
also absorbing oxygen in small amount. Its power of absorbing 
aliments, medicaments, and toxic substances, in either gaseous or 
liquid state, is greatly restricted so long as its horny external 
covering is intact. Such absorption, when it occurs, is probably 
effected through the portal of the ducts of the cutaneous glands. 
Gaseous and volatile substances, as well as several of the oils and 
fats, may at times penetrate the skin through these avenues. 

The skin is provided with a natural unguent, by which, in a state 
of health, it is constantly anointed. The fatty and oily secretions of 
the skin are concerned, not merely in the anointing of the general 
surface and of the hairs, but also in the regulation of the bodily 
temperature, by preventing the maceration of the tissues by the 
sweat. 

The complex organ which is called the skin is essential to the life 
of the individual. The sexual, and possibly other organs of the 
human body, may have their functions arrested, or be even obliterated 
by destructive processes, and life still continue ; but if the functions 
of the skin were all suspended for a sufficient period of time, the 
result would be fatal. In its important relations alone to the com- 
plicated processes by which the heat of the body is maintained at a 
relatively fixed standard, the skin exhibits its importance to the 
general economy. It is thus seen to be, not an isolated membrane 
stretched mechanically over an artificial machine, but one of several 
living and potential systems of the body, each of which is in inti- 
mate union with all others. 

The integument of the body, when studied by the aid of the 
microscope, is found to be composed of several organic parts. These 
are : the subcutaneous connective tissue resting on the deeper struc- 
tures of the body ; then, more externally, the corium, or true skin ; 
lastly, an outermost coat, the epidermis, or cuticle. Beside these, the 
skin contains coil glands, sebaceous glands, hairs, nails, blood- and 
lymph- vessels, muscles, pigment, and nerves. It will be instructive 
to study the deeper parts before those more superficially disposed, as 
their mutual relations are thus made clearer. 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 19 



Fig. l. 




Section of skin from the palm of the hand, magnified 150 diameters, a, stratum cor- 
neum ; a', irs superficial layer ; h. stratum lucidum ; c. stratum granulosurn : d, stratum 
mucosum (rete) ; e, pars papillaris of the corium, loops of capillary vessels showing in vascular 
papilla; ; f, pars reticularis of the corium. showing coarse interlacing connective-tissue bun- 
dles; g, transverse section of the latter; h, double-contoured nerve-fibre passing to tactile 
body ; i. coil-glands : k. ducts of coil-glands : 1. sweat-pores passing to surface of epidermis ; 
m, arteries of the skin terminating in capillaries; n, veins of the skin forming plexuses ; o. 
fat-cells, encompassed by capillary loops, in relation with coil-glands; the capillaries of the 
latter are purposely omitted in the drawing ; p. obliquely and transversely divided bundles of 
connective-tissue fibres of the corium and subcutaneous tissue. 



20 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



Subcutaneous Tissue. 

The subcutaneous tissue is differentiated from the corium between 
the third and fourth months of foetal life. It is a structure serving 
a mechanical purpose as a receptacle for fat, and for the support of 
vessels and nerves passing from the tissues beneath to the corium, 
which lies next above it. It contains, also, coil-glands, some of the 
hair-follicles more deeply seated than their fellows, aud Pacinian 
corpuscles. There is no distinct boundary line between its upper 
limits and the overlying corium, to which it projects columnar masses 
of fat, extending obliquely to the coil-glaods and the hair-follicles 
above, often with lateral, horizontally disposed prolongations of 
similar shape. It is built up of loose connective-tissue bundles, 
prolonged from the aponeuroses, fasciae, and the membranes lying 
beneath. 

Fig. 2. 




Subcutaneous fat tissue, the fat having been extracted by turpentine. B, bundles of fibrous 
connective tissue, carrying injected bloodvessels ; C, capsules of fat-globules, with oblong 
nuclei. Magnified 50C diameters. (After Heitzmann.) 

It is firmly attached to the skin over the extensor surfaces of the 
articulations, the palms, the soles, aud the groins by short and coarse 
bundles, between which are single or multilocular spaces lined with 
endothelia, secreting a mucoid fluid. These are the bursse mucosa?. 
Elsewhere, as in the eyelids, the penis, the scrotum, and the auricle 
of the ear, the attachment to the skin is by loose, delicate connective 
tissue, containing no fat-globules. All other fibrous tracts are 
arranged obliquely, admit, by their extension, of various degrees of 
pliability, and inclose rhomboidal spaces containing more or less 



THE CORIUM 



21 



numerous fat-globules. These are tabulated, bounded by a delicate 
fibrous connective tissue, and abundantly supplied with bloodvessels. 
This is termed the panniculus adiposus. 

The deposit of fat in the body is greatly reduced in all diseases 
productive of emaciation, but never wholly disappears in life. In 
cases of obesity, fat is deposited in excess of normal limits, and may 
then be concerned in the production or aggravation of disease. It is 
largely due to the greater or less volume of the panniculus adiposus, 
that the natural outlines of the body are made graceful and attractive 
to the eye, or the reverse. 

The Oorium. 

The Corium, Derma, Cutis Vera, or True Skix, is composed 
of bundles of fibres of connective tissue, whose decussations produce 
a dense felt-work, coarsest toward the subcutaneous tissue, upon 

Fig. 3. 



d |jgS 




a, Epidermis ; b, erector pili muscle; d, columna adiposse ; c, coil-gland suspended in the 
latter ; p, horizontal prolongations of the column ; /, fibrous bundles of the corium ; g, pan- 
niculus adiposus ; k, band of fibrous tissue extending into the latter. (After Warren.) 

which it rests inferiorly, and finest superiorly in the outermost 
portion, which is in contact with the epidermis above. Its general 
characteristics are described by Heitzmann as follows : " The bun- 
dles are bounded in many instances by a very dense basis-substance, 
representing the elastic fibres, and separated from each other by 
narrow layers of a cement-substance (Thomsa), which, in its chemical 
features, is kindred to the glue-giving basis-substance of the fibrous 
connective tissue in general. In this cement-substance there are 
imbedded delicate formations of protoplasm, greatly varying in 



22 



ANATOMY AND PHYSIOLOGY OF THE SKIN". 



amount in the derma of persons of different age. They represent 
formations analogous to nuclei, "connective-tissue cells," compact 
masses, or delicate reticular layers of living matter, which, with a 
power of five hundred diameters of the microscope, look finely 
granular. The whole glue-giving basis-substance of the bundles is 
traversed by a delicate reticulum of living matter, in direct union 
with all protoplasmic formations between the bundles, with all blood- 
and lymph- vessels, with all nerves, and with the columnar epithelia 




Vertical section of skin after injection, from beneath, of areolar tissue with Berlin blue. 
a, epidermis , /, corium ; g, panniculus adiposus. (After Waeren.) 



nearest to the capillary layer. Only the meshes of the network [of 
the living matter contain the glue-giving basis- substance, which, [as 
the history of development of the connective tissue demonstrates, is 
produced by a chemical alteration of the lifeless protoplasmic fluid 
itself. The bundles of the connective tissue of the derma accompany 
all elongatious of an epithelial character. They produce the follicles 
around the root-sheaths of the hair, the capsules around the coil- 
glands, and the layers which surround their ducts. The bundles of 
connective tissue are traversed in an oblique direction by bundles of 
smooth muscular fibres, by relatively scanty bloodvessels in the 
derma, by numerous capillaries in the papillary layer, by a system of 
lymphatics, and by numerous medullated and non-meduliated nerves. 

Pars Reticularis. — The reticular layer of the corium is made 
up, as has been seen, of interlacing connective-tissue bundles, with 
interspaces increasingly larger from without inward. The fiueness of 
the bundles increases, in the same way, from without inward, being 
finest where the minute papilla? of the corium project into the rete, 
and coarsest near the subcutaneous tissue. 



THE COBIUM. 



23 



Pars Papillaeis. — The papillary layer of the corium lies iu 
contact with the rete above, and is connected below with the deeper 
reticular portion of the true skin. Between the rete and the papilla? 
of the derma a hyaline substance is interposed which Unna believes 
may be identical with the so-called cement-substance described as 
separating the fibrillar of the corium. The basal membrane once 
thought to be stretched between the rete mucosum of the epidermis 
and the papillary layer of the corium, cannot be demonstrated to 
exist. 

Viewed obliquely, with an amplification of about three hundred 
diameters, it can be seen that long and slender filaments from the 
prickle-cells of the mucous layer of the epidermis, described upon 
another page, encircle in a spiral direction both nervous and vascular 
papilla?. At the apices of the latter these threads completely sur- 
round the connective-tissue fibres. 

Fig. 5. 




d o 

Vascular and nervous papilla-, a, vessel: b, nervous papilla: c, vessel: d, nerve-fibre; 
e. corpusculum tactus : /. trausversely divided nervous filaments ; g, epithelia of rete. (After 

BlESIADECKI.) 



The name of this portion of the derma is intended to describe its 
chief characteristic, the existence of numerous digital prolongations 
of the corium, made up of delicate fibres of connective tissue, which 
do not interlace, and are abundantly provided with nuclei. The 
papilla? spring each from a single, or several from a common, ovoid 
base; their bulbous, conical, or blunt apices reaching into the rete, 
which also dips down between them. They differ in size in different 



24 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

parts of the body, and also in their disposition and shape, being in 
places arranged in linear series, and in others in concentric whorls, 
with definite centres, producing thus crossing furrows, visible to the 
naked eye as markings upon the outer surface of the epidermis. 

In horizontal sections of the skin, the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas the inter-papillary reticulum of the mucous layer is seen. 

According to Unna, who bases his statements upon the wide varia- 
tion between the largest sized papillae and their entire absence in some 
regions, the papillary layer of the corium represents merely " an ex- 
tremely variable border-phenomenon. " Certain it is that the growth 
of the rete downward and of the corium upward results in mutual 
effects of pressure and counter-pressure whose equilibrium is con- 
stantly adjusted by the mechanical and vital necessities of such union. 

When the papillae are completely exposed, after the removal of the 
overlying so-called cement-substance and of the epidermis above, 
their exterior surface is seen to be uniformly marked with series after 
series of alternating furrows and ridges of exceeding delicacy, more 
or less concentrically disposed. These are supposed by Unna to be 
grooves with ridges on either side, into which are admitted corre- 
sponding dentations to be recognized on the under surface of the 
layer of epithelial cells next to the corium. They may, however, be 
the furrows left after separation of the long prickles wrapped about 
the papillae and traceable to the mucous layer. 

Two varieties of papillae are distinguished — the vascular and the 
nervous ; the former containing the terminal loops of a minute artery 
and vein ; and the latter, the ultimate filamentous termination of a 
non-medullated nerve-fibre. 

The greater number of papillae are of the vascular variety, being 
traversed by a vertically disposed loop of vessels, consisting of an 
arterial and venous capillary. Their office is evidently not merely 
to supply nutriment for the epidermis above, but also to provide for 
the cooling of the blood when brought in large quantities to the sur- 
face of the body. Occasionally, two or more of such loops can be 
recognized in a single papilla. 

The nervous papillae contain the tactile corpuscles, which subserve 
au important purpose in providing for the sensibility of the integu- 
ment. These are described in connection with the nerves of the 
skin. Ultimate terminations of nerves can be recognized in the 
vascular papillae, and at times minute vascular loops can be seen in 
the papillae largely occupied with the corpuscles of touch. 



The Epidermis. 

The Epidermis, Scarf-skin, or Cuticle, is the most external 
of the several membranes of the body, being in close contact on one 
side with the corium, or true skin, and exposed on the other to the 



THE EPIDERMIS. 



25 



atmosphere by which it is surrounded. The latter surface is there- 
fore relatively drier, while the former is constantly moistened by 
fluids from the vessels which ramify beneath it. 

No genetic relation can be established between the epidermis and 
the corium, intimate as is their union and mutual relationship. The 
former is developed from the ectoderm, the latter from a superficial 
layer of the mesoblast. Their behavior both in health and disease 
is marked by the widest difference. 



Fig. g. 




Scalp of a colored man— horizontal section. E, rete mucosum ; Pi, row of columnar epi- 
thelia, cut obliquely, supplied with dark-brown pigment-granules ; Pa, papilla, cut trans- 
versely ; D, Derma. Magnified 500 diameters. (After Heitzmann.) 



The epidermis differs greatly in thickness in different portions of 
the body, that, for example, of the palms and soles exceeding, in 
vertical section, that which covers the dorsum of these same organs, 
and that protecting such sensitive parts as the lids, lips, temples, and 
prepuce. 

f |The epidermis is composed of the following layers, named in order 
from within outward : the stratum mucosum, the stratum granu- 
losum, the stratum lucidum, and the stratum corneum. Each of 
these several strata, or layers, is histogenetically derived from the 
one which is deeper in situation. 



The Stratum Mucosum, Mucous Layer, Prickle-layer, 
Rete Mucosum, Rete Malpighii or Malpighianum, is the 
deepest of the epidermal layers, and rests upon the corium below. 
The latter is intimately united with it by a series of interdigitations 
which are commonly described as prolongations of the derma into 
the substance of the rete, but it is equally true that the rete sends 
down prolongations into the derma. The two, in the need of an 
intimate union to resist friction and to insure vascular supply, are 
thus closely locked together. 



26 



ANATOMY AND PHYSIOLOGY OF THE SKIN, 



The stratum mucosum is built up of nucleated epithelia, epithelial 
cells, or corpuscles, polyhedral in outline and diffusely colored. 
These are masses of granular protoplasm, living matter, which by 
their relations to each other form a protoplasmic network envelopiug 
the entire surface of the body and liniug all channels and cavities 
which are in direct or indirect connection with the surface. These 
elements are flattened by reason of their apposition, and separated 
from each other by an intercellular substance, which has been 
described as a "cement-substance." There is, without question, a 
system of channels between the epithelia, by which the fluids of 
nutrition are conveyed from cell to cell. All are, however, unin- 
terruptedly united to each other by means of delicate spokes, known 



Fig. 7. 




Prickle cells from a condyloma. Magnified about 625 diameters, a, cavity of cell nucleus ; 
b, nucleus ; c, nucleolus ; d, prickles— these are greatly developed on the protoplasm of the 
cells. The dots on the surface of the protoplasmic mass represent the appearance of the 
prickles when directed toward the eye of the observer. Some of the protoplasmic threads are 
seen passing from one cell to another. 



as prickles, spines, or thorns. The living matter, which produces a 
delicate reticulum within each protoplasmic body, its points^ of inter- 
section being termed nuclei, nucleoli, and granules, furnishes the 
filaments already described, which thus produce continuity through 
all the living layers of the epithelial elements, as well as through the 
underlying layers of the connective tissue. The epithelia are unpro- 
vided with either blood- or lymph-vessels ; but, when living, are 
supplied with a large number of nerves, which, in the shape of very 
minute beaded fibres, traverse the intercellular substance, and are in 
direct communication with the reticulum of living matter within the 
protoplasmic bodies themselves. 

The living masses of protoplasm, just described, play the most 
important part in all the pathological and physiological processes 



THE EPIDERMIS. 27 

observed in the skin. It is probable that, in the embryo, all the 
appendages of the skin are formed directly by their assimilative and 
reproductive processes ; and it is certain that, in health and disease, 
they furnish the organic matter of all secretions. 

The epithelia next the corium are columnar in form, of a diffuse 
brownish hue, and arranged with their long axes nearly at right 
angles to the plane of that portion of the corium upon which they 
are superimposed. More externally they have pronounced polyhedral 
outlines, and the cell nucleus of each is large and distinct. 

Above this columnar-shaped pavement, irregularly rounded and 
cubical epithelia, with large, single or multiple, spherical nuclei, are 
packed between the papillae of the corium, rising from below ; and 
horizontally flattened bodies of the same general appearance lie in 
strata above the level of the conical apices of the papillae. Here the 
threads of protoplasm between the cells are voluminous, forming 
thick and broad strands connecting the elements. Between these, 
outwandered leucocytes may at times be recognized. In the more 
externally disposed rows of epithelia the prickles become shorter 
and the cells flatter, till finally they lie in a uniformly horizontal 
plane. 

The Stratum Granulosum, or Granular Layer of the epi- 
dermis, is built up of one or two, rarely more, rows of horizontally 
disposed granular bodies, united to each other by short and broad 
threads. Between these, the intercellular spaces are so contracted 
that nutritive fluids cannot filter easily outward ; and the nuclei of 
the cells are usually skrunken in size. These have been carefully 
studied by Ranvier, Kolliker, Waldeyer, and others. According to 
these observers, the roundish granules which give this layer of epi- 
thelium its peculiar name and appearance, consist of eleidin, or 
kerato-hyalin, a substance essential to the process of cornification in 
the elements making up the horny layer of the skin, nails, etc. 
These granules begin to appear in the neighborhood of the nuclei of 
some of the large prickle-cells in the rete, but are best studied in the 
granular layer, whose cells are often completely filled with them. 
According to Unna, the color of the skin in the white races depends 
upon this layer alone. 

The Stratum Lucidum, or Septum Lucidum, of Oehl, lies 
immediately above the stratum granulosum, and appears under the 
microscope as a delicate, brightly colored line, consisting of two or 
three rows of transversely disposed, glistening epithelia, differing in 
translucency from those situated on either side. It thus marks with 
tolerable distinctness the boundary lines of the rows of cells above 
and below it. Its epithelial bodies have suddenly lost the refractive, 
shining granules of kerato-hyalin, conspicuous in the stratum granu- 
losum below. These granules are generally supposed to have disap- 
peared in consequence of their solution in the protoplasm of the cell- 
body, which has thus acquired an added brilliancy and clearness. 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The Stratum Corneum, or Horny Layer of the epidermis, is 
its outermost and widest layer, extending from the stratum lucidum 
below to the external environments of the body. In its lower por- 
tion, the polygonal plates of which it is composed indicate very 
clearly their relationship to the cells in the prickle-layer. The nuclei 
appear in places, only, as shrivelled and inconspicuous relics of the 
protoplasmic threads. Occasionally, on the edges, rudiments of the 
prickle-threads may still be recognized. Still more externally, the 
dried, lifeless, and horn-like plates of which this layer is composed, 
become mere cornified shells, generally lying in horizontal strata, 
more curled and wrinkled as the surface of the skin is reached, often 
imbricated, but preserving the polygonal outlines of epithelia relieved 
of the forces of pressure aud counter pressure exerted in the deeper 
parts of the epidermis. These elements are rarely pigmented, save 
in the case of the negro, where the intense staining of the deepest 
parts of the mucous layer is to a degree spread to the external strata. 
Such staining in the colored races is produced by granules of pigment 
arranged about an unaffected nucleus in the prickle- cells. 

According to Unna, after digestion with pepsin and trypsin, it is 
seen that the horny cells are connected by more or less persistent 
threads, visible after more prolonged digestion as a large-meshed 
reticulum, with strands formed from a double row of cornified fila- 
ments united by short horny bridges. 



Bloodvessels. 

The Arteries and Veins supplying the skin spring from sub- 
cutaneous branches which penetrate the fasciae beneath, and proceed 
by subdivision to be distributed to all portions of the integument 
below the epidermis, the distribution being especially abundant about 
the glands and follicles of the skin, and the inferior and superior 
parts of the corium. They are always more abundant upon the 
flexor than the extensor faces of the extremities. Just beneath the 
papillary layer of the corium there is a minutely ramifying plexus of 
fine capillaries, whose loops extend into the papillae above, as already 
described. This and the coarser plexus in the deeper portion of the 
derma are so well defined that they might well be designated as 
superior and inferior partes vasculares of the corium. Still a third 
vascular tissue is found in the subcutaneous connective tissue where 
the vessels are numerous. 

The arterioles which supply the sweat-glands surround the coils 
of the latter in a delicate basket-like plexus, and terminate in two 
or three veinlets, one of which always accompanies the duct of the 
gland upward as far as the papillary layer, where it anastomoses 
with the vessels of that part of the skin. The ascending arterioles 
supply also the sebaceous glands and hair-follicles ; and, finally, 
breaking up into smaller and yet smaller branches, furnish a single 
or double capillary loop to each papilla. The capillaries of the 



LYMPHATIC VESSELS. 29 

papillary layer anastomose freely with those transversely arranged in 
the upper portion of the hair-follicle, loops from which also pass to 
the sebaceous glands. The hair- papilla has a vascular supply similar 
to that of the other papilla? of the corium. 

Unna divides the vessels distributed to the skin into the papillary 
system and the system of the coil-glands and fat tissue. The former 
includes the ascending loops which traverse the vascular papillae, and 
the branches supplying lower portions of the corium. The latter 
embraces the vessels running upward to the coil-glands and down- 
ward to the fat tissue. In the papillary vascular system, the arteries 
are narrow and the veins wide. The vessels consist merely of an 
endothelial tube augmented, as the subcutaneous tissue is reached, by 
both media and adventitia. According to Hoyer, there is a singular 
duplex arrangement of vessels in the distal phalanges of both fingers 
and toes, in consequence of which there is a distinct communication 
between the arteries and veins. 

Vasomotor nerves are twined around these vessels in all their 
ramifications. The whole vascular system, as thus arranged, plays a 
most important part in all the healthy and morbid processes which 
occur in the skin, as well as in the sudden physiological changes dis- 
tinguishable to the eye in the phenomena of blanching and blushing. 



Lymphatic Vessels. 

The skin in all its parts is provided with a system of lymphatic 
channels, designed to subserve the necessities of the important pro- 
cesses of absorption, and traversed by lymph whose currents are 
continuously directed to the large vessels of the structures beneath 
the skin. Unna divides these channels into : first, juice-spaces, pro- 
vided or not with independent walls, usually the latter, and not 
freely communicating with the endothelium-lined vessels ; second, 
lymphatic vessels proper, which communicate directly with the blood- 
vessels. 

The juice- or lymph-spaces separate the epithelial bodies that make 
up the stratum mucosum of the epidermis, and also extend between 
the protoplasmic threads or prickles that unite them. Such conduits 
may be regarded either as delicate excavations in the so-called cement- 
substance between the epithelia, or as irregular channels in a softish 
viscid, albuminoid, and readily coagulable substance existing between 
the protoplasmic threads. In the latter event, these spaces would be 
comparable to the impressions made by thrusting at random a pencil 
into a mass of soft putty. At times, this intercellular substance 
seems capable of obstructing the conduits by which it is tunnelled. 
These same juice-spaces exist in the papillae of the corium, and 
encircle the several glands, hair-follicles, and nail-beds of the skin. 
They also sheath the connective-tissue fibrillar of the corium and 
surround the fat-cells. 

The lymphatic vessels are relatively few, but form a continuous 



30 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

mesh work with transversely and vertically disposed branches sup- 
plying all parts of the skin below the epidermis. The juice-spaces 
communicate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As they pass to the 
deeper portions of the corium and below it, these vessels increase in 
size. 

The current of the lymph is from the papillary apices in every 
direction to all parts of the rete, like the currents in the delta of a 
river, a reflux occurring at the lower limit of the interpapillary 
depressions of the rete downward, possibly through the sweat-pores 
which traverse the epidermis at these points. Thence the current 
flows freely downward to the lymphatic vessels in the corium, but 
the stream from the juice-spaces about the coil-glands and fat tissue 
is retarded by reason of a more restricted communication with the 
lymphatic vessels below. In consequence of the retardation due to 
this anatomical peculiarity, the formation of fat by filtration is 
facilitated. 

Nerves. 

Non-mednllated and medullated nerve-fibres, each in places being 
substituted for the other, are supplied to the skin from horizontally 
disposed bundles of nervous twigs in the subcutaneous tissue. These 
traverse the corium in connection with the bloodvessels, and become 
finer as they ascend, till they form a subepithelial plexus just below 
the epidermis. 

Exceedingly delicate Non-medullated Fibres penetrate to the 
epidermis between the epithelia in great abundance. Here, traversing 
the intercellular substance by the side of the juice-spaces, they either 
terminate between the prickle-cells as ultimate bulbous terminations 
of finely beaded fibrillar, or they penetrate the epithelia themselves 
in pairs. Each prickle-cell is supplied with a pair of these beaded 
filaments, which may be either applied to the nucleus of the cell, or 
be seen to encircle the nucleus more or less completely. Above the 
stratum granulosum these nervous threads cannot be recognized. 

Similar nervous filaments are supplied to the sheaths of the hairs 
and the ducts of the coil-glands. It is by means of these numerous 
and delicate fibres that the perception of sensation in the skin is 
accomplished. 

Motor filaments, discovered by Thomsa, are also distributed to the 
sheaths of the bloodvessels, in which they are finally lost. Other 
motor filaments supply the muscles, and trophic nerves are distributed 
to all the secreting organs of the skin, and to all its protoplasmic 
formations. 

The Medullated Nerve-fibres of the skin have been care- 
fully studied by Dr. A. R. Robinson, 1 of New York. According to 

1 A Manual of Dermatology, by A. R. Robinson, M.B., etc. New York, 1884. 



NERVES. 



31 



the latter, one or several loops of such fibres pass upward into the 
papillse, and then turn backward to the subpapillary region. Some 
of these, after such reversion, again ascend to an adjacent papilla. 
Yet others are supplied to the Pacinian and tactile corpuscles. 

The Pacinian Corpuscles, named from the anatomist Pacini, 
also called Corpuscles of Yater, exist subcutaueously only upon 
nerves intended for cutaneous supply, and are small, oval bodies, 
two or more millimetres in diameter. Each consists of a series of 
concentric, nucleated, and vascular capsules, arranged after the man- 
ner of the capsules of the onion, more closely united at the periphery 

Fig. 8. 




Pacinian body, after silver staining, 
showing superimposed endothelial 
layers. (After Renatjt.) 



Section of Pacinian body, from a duck's bill. 
g.L., lamellar envelope; g.h,, hyaline zone of 
the lamellar envelope ; bt, terminal bulb of 
the nerve; g.p., n.g.p., layer investing the 
cavity of the body. (After Renatjt. ) 



than at the centre, and surroundiug a protoplasmic core. The 
medullated nerve to which the body is attached gradually loses its 
myeline envelope, and terminates in the centre of this core, after 
traversing the greater part of its axis, in one or several, minutely 
club-shaped, nervous filaments. The myeline sheath is lost in the 
tissue of the concentric capsules. According to Ranvier, the nerve 
may, after supplying one capsule, subsequently penetrate a second, 
or even a third. In such cases the nerve regains its sheath as it 
issues from the corpuscle at its opposite pole. Robinson believes 
that the nerve forms a plexus or loop within the corpuscle, and again 
leaves it at one of its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since 



32 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



these bodies are most numerous in the subcutaneous tissue of the 
nipple, the penis, the digits, and parts similarly sensitive. It bears 
an evident aualogy to the organ of vision, each body having a cap- 
sular character ; each being provided with a special nerve-filament, 
which enters the corpuscle at one pole ; each also receiving its im- 
pressions at the extremities of the capsule opposite that where it 
receives its nervous supply. 

According to Krause, the Pacinian corpuscles are concerned in 
the appreciation of impressions produced by pressure and traction. 



Fig. 9. 




Section of a papilla still covered by a portion of the stratum mucosum and containing a 
tactile body, from the skin of the finger. The corpuscle of Meissner is seen to consist of minute 
lobules, made up of a homogeneous protoplasm, with numerous oval nuclei and nervous 
fibrillee wound in a spiral direction about the mass of the -corpuscle. The extension of the 
fibrillse to the mucous layer is shown. The sources of the nerve-filaments are demonstrated to 
be: (1) the axis-cylinders of one or two double-contoured nerve-fibres, splitting into their 
original fibrillse on arriving at the corpuscle, wiuding about the latter in characteristic spirals, 
and passing to the palisade layer of the prickle-cells of the rete, between which, on account of 
the long prickles of the latter and the general resemblance of the two in thickness and con- 
tour, it is difficult to trace them further ; (2) filaments from another double-contoured nerve- 
fibre (h) pass directly to the inferior layer of cells in the rete without establishing relations with 
the tactile body ; (3) fibrillse derived from the network of nervous fibrillse in the pars papillaris 
of the corium (K), also passing more or less directly to the stratum mucosum. a, cells of the 
rete ; b, prickles of the latter ; c, body of papilla ; d, nuclei of connective tissue forming 
papilla : e, protoplasmic part of the tactile body Avith its nuclei ; f, fibrillse of the corpuscle ; 
g, double-contoured nerve-fibres directly supplying the rete ; k. nervous fibrillse derived from 
the network in the pars papillaris ; 1, nervous fibrillse entering the epidermis between the rete 
cells, leaving the corpusculum tactus at m. 



NERVES 



33 



Whether specially concerned in the distinguishing of sensations 
originating in heat, cold, moisture, pressure, traction, or weight, it is 
evident that they contribute but little, if at all, to the reception of 
ordinary impressions upon the skin, and, at this date, they are not 
known to play any part in cutaneous diseases. 

The Tactile Corpuscles (Corpuscles of Meissner, or Wagner) 
are other oval-shaped bodies found in about one in four of the 
papilla? in the pars papillaris of the corium. They are composed of 
from one to three capsules. Minute lobules of a homogeneous proto- 
plasm with oval nuclei are found in each. They receive medullated 

Fig. 10. 




Transverse section of nervous papilla surrounded by cells of the stratum mucosum. a, pro- 
toplasmic lobules of the corpusculum tactus ; b, nervous fibrillse spirally wound about the 
latter ; c, transverse section of double-contoured nerve-fibres ; d, cavity of nucleus, out of focus. 



nerve-fibres and are made up of closely compressed, flat, connective- 
tissue fibres with minute nuclei, which are so packed together as to 
form a spindle-shaped mass, occupying the greater part of the papilla 
in which each is found. A somewhat denser connective-tissue cap- 
sule encloses each. The myeline sheath of the nerve-fibres is lost in 
the fibrous tissue of the corpuscle. Externally viewed, they seem 
to be transversely striated. 

The axis-cylinder of the nerve-filament distributed to each divides 
into numerous delicate nervous threads which in part encircle the 
corpuscle and also penetrate within. According to Dr. Robinson, 
each corpuscle is provided with an afferent and efferent nerve, the 
former approaching the corpuscle from the subpapillary region and 
entering at or near its base. Occasionally the afferent fibre is fur- 

3 



34 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

nished by an adjacent papilla. As the filament that enters the 
corpuscle frequently divides, two or more efferent fibres may then 
escape from it. Afferent fibres reach the rete above after encircling 
the tactile corpuscle ; others, side by side, arrive at the rete without 
coming into contact with the former. 

The discovery of nervous filaments in and among the epithelia of 
the epidermis in such abundance as to provide fully for tactile sen- 
sation in the skin, leaves the exact function of these corpuscles in 
partial obscurity. There can be little doubt, however, as to their 
association with the perception of certain qualities of foreign bodies 
with which the skin may be brought into contact. 



Pigment. 

The hue of the living integument is due in part to the degree of 
vascularity and distention of the vessels in the corium, and in part 
also to pigmentation of the epidermis. This pigmentation depends 
upon a distinct and uniform coloration of the epithelia, chiefly those 
found in the lower strata of the epidermis, and also to minute 
granules of pigment entangled in the reticulum of living matter in 
the same part. Extreme variation in the distribution of pigment is 
noticeable both in health and disease, and in individuals and races, 
being at times proportioned to climatic and similar influences. This 
is well illustrated by the wide range between the flaxen-haired and 
pink-eyed albino, and the blackest specimens of the negro, each, with 
small exception, of African descent. 

It has been already noted that in the colored races the pigment 
may stain the epithelial cells and their nuclei as high as the granular 
layer ; and that to this layer only the peculiar color of the skin of 
the white races is due. Pigment is not found normally either in the 
horny layer of the skin or in the subepithelial tissues. Waldeyer 
claims to have recognized it in normal connective tissue. 

The relation existing between the two sources of skin coloration, 
viz., the blood and the pigment, is interesting and suggestive. The 
eye, unaided, looking at the outer surface of the body, makes no dis- 
tinction between these two color sources. It is indeed probable that 
the pigment originates from the coloring matters of the blood. It 
is certain that solar heat exerts a manifest influence upon both, and 
that in extravasatious of blood into the substance of the skin, every 
shade of color which can be detected in the spectrum can be at times 
distinguished. 

Muscles. 

Striated Muscular Fibres extend from the subcutaneous tissue 
into the derma, and in the case of man are found chiefly upon the 
face aud neck, where they are the analogues of more powerful skin- 
moving muscles possessed by several of the lower animals. Some, 



HAIRS. 35 

as those in the region of the face, serve to give expression to mental 
emotion by the production of movements in the features. 

Non-striated Muscular Fibres exist either as minute oblique 
fasciculi in connection with the glands and follicles of the skin ; or as 
annular bands, such as those which surround the nipple ; or as 
radiating and more or less parallel rods, such as antagonize the 
orbicularis in the lids. 

The Arrectores, or Erectores, Pilorum are muscles found 
usually in connection with the hair-follicles. They originate by 
minute multiple fasciculi from the papillary portion of the corium, and 
are inserted at several points into the outer layer of several adjacent 
hair-follicles, just above the plane of the apex of the hair-papilla. 
Their general direction is oblique, and their muscle-bundles are both 
embraced aud traversed by elastic fibres which form a dense network 
about them. Elastic threads also connect them intimately with the 
connective- tissue bundles of the corium, and serve as tendons at 
either extremity of each muscular fasciculus. 

The oblique direction and mode of attachment of these muscles 
result in their inclusion of the sebaceous glands connected with the 
hair-follicles in the angle subtended by their muscular fibres. It 
follows, therefore, that by their contraction they can aid in the 
expulsion of the sebaceous secretion formed in the gland. But their 
intimate union with the elastic tissue, which is evenly and generally 
distributed throughout the framework of the corium, results in their 
discharge of a still more important function in connection with the 
regulation of the bodily temperature. Their anatomical connections 
are such that contraction of the arrectores pilorum serves to approxi- 
mate several of the papilla? of the corium, the hair-papilla being in 
this view regarded as one of such cones. Thus, by their contraction 
the sebaceous secretion may be extruded, or, as is more particularly 
exhibited in the lower animals, such hairs as the bristles of the 
boar may be erected. But by virtue of direct compression exerted 
upon the skin, the blood may be driven from the surface in a centri- 
petal direction and its cooling to a great degree prevented, as in the 
well-known phenomena resulting in the production of the cutis 
anserina or " goose flesh." The reverse of this naturally follows 
when the muscles expand under the influence of external heat. 



Hairs. 

Hairs are cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions 
in the rete and corium, known as hair-sacs, or hair-follicles. They 
are found in all portions of the body except the palms and soles, 
the dorsum of the distal phalanges of the hands and feet, aud the 
skin of the penis. Hairs occur in three tolerably distinct classes. 



36 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



There are the fine downy hairs, or lanugo, covering the face, trunk, 
and limbs ; the long and soft hairs, such as are implanted upon the 



Fig. 11. 



Fig. 12. 





Section of hair-follicle during the forma- 
tion of a new hair, a, external and middle 
root-sheaths ; b, vitreous membrane ; c, pa- 
pilla, with vascular loop ; d, external root- 
sheath ; e, interna] root-sheath ; /, cuticle of 
hair-follicle ; g, cuticle of hair ; h, i, young 
hair ; I, bulb of old hair ; k, debris of exter- 
nal root-sheath of hair recently expelled. 
(After Ebner.) 



Hair-follicle in longitudinal section, a, 
mouth of follicle ; b, neck ; c, bulb ; d, e, dermic 
coat ;/, outer root-sheath , g, inner root-sheath; 
h, hair ; k, its medulla ; I, hair-knob ; m, adi- 
pose tissue ; n, hair-muscle ; o, papilla of 
skin; p, papilla of hair; s, rete mucosum, 
continuous with outer root-sheath ; ep, horny 
layer , t, sebaceous gland. 



scalp, pubes, and axillae ; and the short hairs, iucluding the soft 
varieties seen upon the brow, and the stiff hairs of the lids. 



HAIRS. 37 

The hairs are first developed in the third month of foetal life, 
when a short epithelial cone is formed, whose base is gradually 
surrounded by connective-tissue cells, and finally indented from 
below by a rudimentary hair-papilla. Gradually the tip of the 
rudimentary hair perforates the primitive hair-cone, and becomes a 
mature filament. 

At about the period of birth, sometimes earlier, occasionally later, 
the bed-hairs, as they are called by Unna, are replaced by papillary 
hairs. The term bed-hair is applied to primary hairs unprovided 
with papillae, and implanted in shallow follicles from the sides of 
which productive epithelial offshoots have been sent out. Usually 
at the end of foetal life these bed-hairs have been for two months 
growing out of the hair-bed, or that part of the epithelium found in 
the central part of the hair-sac. 

In studying the mature hairs, the parts to be considered are the 
hair-follicle ; and the bulb, shaft, and point of the hair. 

Hair -follicle. — The hair-follicle is a sac-like depression in the 
corium, in which the hair-filament is implanted by its bulb, and 
there firmly secured. The direction or set of this follicle is always 
at an oblique angle with the plane of the cutaneous surface where 
it opens ; and thus is determined the set of the hairs, which is 
always fixed, and at a similar angle. Viewed as a whole, the integu- 
ment of the body over its entire area exhibits determinate whorls of 
both short and long hairs with definite centres, such as those which 
may be recognized at the vertex of the scalp, the centres of the lips, 
the umbilicus, etc. By this disposition the symmetrical appearance 
of the hairy parts is preserved, and, as a consequence of the same 
provision, physiological loss of the hair of the head is not productive 
of deformity, but rather adds dignity to the aspect of the elderly 
man. 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is embedded in the skin, together with the envelopes 
of the latter, termed its sheaths. Above the sebaceous glands the 
limits of the hair-follicle are lost in the papillary layer. It is con- 
stituted of the connective tissue of the corium in three layers : an 
external, longitudinal, fibrous layer ; a middle, transverse layer ; and 
an internal, homogeneous, or vitreous layer. At the base of the 
sac a fibrous pedicle may often be traced as low as the subcutaneous 
tissue. 

If the hair-pouch were made artificially by thrusting into the skin 
from without inward a blunt-pointed pin, before which the tissue 
was gradually pushed, it is evident that the external layer, the 
stratum corneum, of the epidermis would be the first depressed, and 
finally cover the inner surface of the pouch. This represents the 
inner root-sheath of the hair. Next to this the pin would carry 
before it the mucous layer of the epidermis, which then would form 
the outer root-sheath of the hair. Outside of both would lie the 
connective tissue of the corium ; this is the hair-follicle. 



38 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



The Outer Koot-sheath, or, as some prefer to call it, the 
prickle-layer of the hair-follicle, accompanies the involutions of the 
stratum corneum, and the stratum granulosum from without, into 
the funnel-shaped neck of the hair-pouch as far as the openings of 

There, abandoned by the two 



the ducts of the sebaceous glands 



Fig. 13. 




Lower portion of hair-pouch from the lip of a kitten. F, follicle ; T, transverse section ot 
connective-tissue bundles of derma ; M, arrector pili muscle ; IS, inner root-sheath ; OS, outer 
root-sheath ; P, papilla ; C, cuticle ; E, root of hair ; H, hyaline, or so-called structureless 
membrane. Magnified 500 diameters. (After Heitzmann.) 



other layers of the epidermis, it is thinned in proportion as the 
papilla, which rises from below and which it closely surrounds, in- 
creases in size. It thus forms a hollow cylinder traversed by the 
hair and its envelopes, with a relatively wide, external, funnel-shaped 
opening, only partially filled by the shaft of the hair, and a narrower 
opening within, which embraces the neck of the hair-papilla. 



HAIRS. 39 

The Inxer Root- sheath, or, as Urma prefers to call it, the 
matrix of the root-sheath, is externally in relation with the outer 
root-sheath or prickle-layer of the hair-follicle. The protoplasm of 
the cells of which it is constituted contains kerato-hyalin in varying 
quantities, the amount being naturally greater in the cells lying 
nearest the hair-fi lament. The part of the sheath formerly termed 
Henle's layer is the more exernally situated, cellular envelope of this 
internal root-sheath, most conspicuous in that part of the hair-sac 
which is above the level of the papilla. That part of the sheath 
formerly called Huxley's layer is the more internally situated part 
of the same sheath, somewhat higher in the follicle. Both of these 
terms are now falling into desuetude as not actually descriptive of 
distinctly different structures, but only of one structure in different 
situations. That structure, whether it is termed the internal root- 
sheath, or matrix of the root-sheath, springs from the neck of the 
papilla, and rises as high as the neck of the follicle. It contains 
kerato-hyalin, which is actively concerned in the cornifi cation of the 
hair tissue. 

Between this structure and the cells constituting the cortex of the 
hair, there is found, according to Unna, the common matrix of the 
cuticulae, forming respectively the cuticle of the root-sheath and the 
cuticle of the hair. The former is composed of cells with their long 
axes parallel to the circumference of the hair, while those forming 
the cuticle of the hair are arranged perpendicularly to the surface. 
These cuticulae are securely locked together by projection of their 
cell edges, while united in the hair-follicle. 

The Bulb, or Root, of the hair is that portion which is imbedded 
in the skin, toward which the shaft of the hair gradually increases in 
thickness as it descends. It is embraced by the hair-follicle, though 
its root-sheaths are interposed, and implanted below at the base of 
the sac upon a nipple-shaped prolongation of the corium, which may 
be regarded as analogous to the vascular papillae of the papillary 
layer of the corium. 

The bulb of the hair embraces the papilla, and is constituted of 
pigmented cells externally, forming what is called the cortex or 
cortical portion. This is the larger of the two structures of which 
the hair is composed, and its cells become vertically elongated and 
narrow as they are pushed outward in the process of growth. 

The innermost structure of the hair is called its medulla, a tissue 
composed of non-pigmented, horizontally broadened cells containing 
kerato-hyalin. It rests directly upon the apex of the papilla below, 
and passes thence through the centre of the shaft of the hair like a 
delicate cylindrical core. Air-spaces occur between its epithelial 
cells as it rises toward the funnel-shaped opening of the hair-sac, but 
air does not enter the body of the individual cells. 

The Shaft of the Hair is that portion which extends from 
its exit at the surface of the skin to its extremitv. The latter, when 



40 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



Fig. 14. 



uncut, always tapers to a perfectly acuminate point, as is illustrated 

in the uncut hairs of the lids, and of the lower animals. The shaft 

is either straight, curled, wavy, or al- 
ternately varied in diameter, producing 
the peculiar character of the growth 
seen upon the scalp of the negro, these 
variations being due to the different 
degrees of flattening of the shaft in a 
transverse direction. 

The color of the hair is dependent 
upon the pigment it contains, the proper 
color of the hair-cells, and the quan- 
tity of air contained in the medulla. 
Variation in these three factors pro- 
duces the wide range between a snowy 
whiteness and an ebony black. 

The membrane which invests the 
shaft of the hair is the cuticle, already 
described, composed of numerous flat- 
tened plates, regularly overlaid so as to 
resemble fish-scales when viewed under 

the microscope on the flat side, and the overlapping shingles of the 

roof of a house when seen on the edge. 




Transverse section of hair and 
follicle. 



The Cortical, or main, Substance of the Shaft of the hair 
is here also enwrapped by the cuticle, and composed of flat, nucleated, 
fusiform, epidermal cells. The strength, elasticity, and extensibility 
of the hair are chiefly due to the cortical substance, and in particular 
to the firmness with which these epidermal cells are attached to each 
other. 



The Medullary Substance of the Shaft of the hair is 
fouud best developed in the short and strong hairs of the beard and 
eyelashes, being wanting in the lanugo hairs. It consists of a loosely 
packed mass of epidermal elements, differing in shape, developed in 
the centre of the axis of the shaft. This part of the hair contains 
also the pigment and fatty matters which are here arranged as in the 
rete of the epidermis. Seen under the microscope, the medulla 
appears as a continuous or interrupted longitudinal band, extending 
from the bulb, or the part implanted in the follicle, to the extremity, 
or point. The purpose of this difference in the constitution of the 
cortex and medulla of the hair is doubtless to insure, on well-known 
mechanical principles, a maximum of strength, extensibility, and 
elasticity, with a minimum of volume. 

The coloring matter of the hair is stored in both its horny and 
medullary portions, and is distinct both within and between the 
epithelial elements of which it is composed. This pigmentation cor- 
responds, as Heitzmann has shown, in great part to the amount of 
pigment distributed to other parts of the integument, and sustains a 



SEBACEOUS GLANDS. 41 

close relation to the general nutrition of the body. Its subjection to 
the influence of the trophic nerves is well demonstrated by the phe- 
nomena of rapid blanching of the hairs. Excessive sweating, whether 
physiological or induced by the action of pilocarpine, has also a 
distinct influence upon the shade of color of the hair. 

On transverse section hairs present an ovoid or ellipsoidal outline, 
occasionally suggesting an irregularly compressed circle. The degree 
of this flattening differs in different races, and, as has been shown, 
is the cause of variability with respect to straightness or curliness. 
As hairs are to a marked degree hygroscopic, and not only absorb 
but can be deprived of a portion of their water, these states of 
waviness are subject to variation according to the aqueous condition 
of the media by which an individual is surrounded. 

Hairs differ from nails not only in their anatomical features, but 
particularly as to their physiological reproduction. The former are 
periodically cast off and replaced by new filaments ; the latter are so 
shed and re-formed only in disease, and in health enjoy a continuous 
growth during the life of the body. 

When a hair is about to be shed it separates from its papilla in the 
hair-follicle and rises in the latter till it reaches above the level of the 
papillary apex. It is thus for a time held in place with sufficient 
firmness by the prickle-layer only, and thus forms the bed-hair 
described above. Later an epithelial bud is projected either into the 
vacant follicle below or into the corium on either side, from which a 
new hair is formed, somewhat as the hair is formed in the primitive 
cone of foetal life. Later the growth outward of the new papillary 
hair pushes the bed-hair from its connection with the prickle-layer, 
and the latter is shed. 

Sebaceous Glands. 

The sebaceous glands are pyriform bodies, usually racemose in 
development, situated in the corium, never in the subcutaneous tissue, 
which furnish a more or less consistent and fatty secretion destined 
to anoint the skin and hairs. They can be usefully distinguished as 
in three separate classes, though only two of these classes include 
glands which are in the embryo associated with hairs. 

The first class, as proposed by Sappey, includes the sebaceous 
glands, which are, strictly speaking, appendages of the hairs and 
hair-follicles. They are developed early in foetal life from minute, 
lateral, bud-like prolongations from the outer root-sheath of the hair. 
From two to six of these spring from the prickle-layer of the hair- 
follicle ; and the prickle-cells in the axis of each bud speedily undergo 
fatty metamorphosis. In the mature gland each acinus is formed of 
a membrana propria, on which are ranged layers of nucleated 
cuboidal epithelia undergoing fatty metamorphosis. Gradually the 
fatty cells are pushed outward toward the duct of the gland, where, 
sooner or later, their rupture releases numerous drops of fat just 
where the hair emerges from the closely applied follicle below to the 



42 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



funnel-shaped mouth of the hair-pouch above. Externally, each 
gland is provided with a layer of connective tissue. On account of 
the clearly defined relations of these bodies, Unna would call them 
the " glands of the hair-follicles.' 7 They are found in connection 
with the long and soft hairs, as of the scalp and axillae, several 
grouped around a single hair-sac. 

Fig. 15. 




Sebaceous glands of the second class from the alee of the nose. (After Sappey.) 

The second class includes the large and complex glandular struc- 
tures to which the lanugo, or rudimentary hairs, seem accessory, the 
orifice of their ducts opening directly upon the cutaueous surface. 
These are chiefly found upon the so called non-hairy portions of the 
skin, as the face in both sexes, and portions of the trunk and 
extremities. 

The third class includes much the smaller number. These are 
sebaceous glands opening directly upon the surface and unconnected 
with hairs or hair-follicles. Such are the glandulae odorifera? of the 
male and female genitalia (glands of Tyson), the Meibomian glands, 
and those existing about the lips and in the areola of the nipple. 
These might be designated as the " glands of the mucous orifices." 



COIL-GLANDS. 43 

The sebaceous secretion is found to contain, chemically, water, 
palmitic aud oleic acids, palrnitin and olein, soaps, and the saline 
constituents of the other organic animal compounds, chlorides and 
phosphates of the alkalies aud earths. It has been already shown 
that the extrusion of the secreted sebum from the ducts of these 
glands is greatly favored by the action of the arrectores pilorum 
muscles, by whose contractions the glaud is to a degree compressed. 
This is the reverse of what occurs in the coil-glands, whose secretion 
is impeded by the action of these same muscles. 



Coil-glands. 

The Coil-glands, also termed Sweat, or Sudoriparous 
glands, are globular coils situated in the subcutaneous tissue and in 
the deeper portions of the cor in m. They appear first in the fifth 
month of foetal life as buds projected downward from the prickle- 

Fig. 17. 




Coil of the sweat-gland. S, tubule lined by cuboidal epithelia ; T, central calibre of the 
tubule ; D, beginning of the duct ; C, connective tissue with injected bloodvessels. Magnified 
500 diameters. (After Heitzmann.) 

layer of the epidermis. Unna has demonstrated that these projections 
always form between the papillae of the corium, and spring from the 
prolongations of the rete between these papilla?. Long, thin cones 
of epithelium thus gradually traverse the corium, and become slightly 
bulbous at the lower extremity to form later the coil. The lumen, 
when formed, extends rapidly to the epidermis, and after this is 
reached, an opening is made from within outward, which becomes 
the sweat-pore. 



44 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



These glands after birth are found in all parts of the body, but in 
certain regions, such as the axillae, the groins, the palms, the soles, 
and about the anus, they are either numerous, of unusual size, or 
peculiarly arranged. They are specially numerous in the palms and 
soles, where, according to Krause, there are between two and three 
thousand to the square inch. 




The sweat-pore traversing the epithelial layers of the skin. BP, papilla with injected blood- 
vessels ; V, valley between two papilla ; D, duct in the rete mucosum ; E, E, epidermal layer ; 
PL, coarsely granular epithelia, deeply stained with carmine ; P, duct with corkscrew wind- 
ings in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

The coil is a convoluted tube terminating in a csecal pouch, lined 
with cubical epithelia of granular appearance, which are the secretory 
cells of the gland. Outside of these are muscular fibres running 
parallel with or in a spiral direction about the coil. Surrounding 
both muscle-bundles and epithelium is a connective-tissue membrane. 
The glomerulus, or coil, is globular in outline and reddish-yellow in 
color. In the larger glands irregular dilatations and constrictions 
of the tube are conspicuous. 

The excretory duct of the coil-gland passes from the glomerulus 
below to the epidermis above, in a straight or spiral course. It is 
lined with a delicate hyaline cuticle, discovered by Heynold, beneath 
which is a double layer of cuboidal epithelium. Externally is a 
membrana propria, unprovided with muscular fibres. Its outermost 
sheath is the usual connective-tissue layer. When the duct reaches 
the border-line of the epidermis, its inner cuticle and external con- 
nective-tissue sheath are both lost. Here it becomes the sweat-pore. 

The Sweat-pore is a continuation of the excretory duct of the 
coil-gland after the loss of its cuticle and connective-tissue sheath. It 
is the loss of these sheaths and the consequent intimate relation of the 
canal to the epithelia of the epidermis that furnish the special basis 



COIL-GLANDS. 



45 



for this distinction. The sweat-pore is merely a wall-less canal or 
channel, spirally directed or running a straight course from the duct 



Fig. 19. 




Section of skin from the palm of the hand (hardened in Moeller's fluid and treated with 
glacial acetic acid), magnified 300 diameters, showing epidermis and pars papillaris of the 
cormm traversed by the excretory duct of a coil-gland terminating in a sweat-pore, a, stratum 
corneum ; a', its superficial layer, the cells in the upper and lower layers somewhat larger than 
those situated between the two ; b, stratum lucidum ; c, stratum granulosum ; d, stratum 
mucosum ; e, rete pegs ; f, interpapillary process of rete meeting duct of coil-gland ; g, g, 
papillae embraced by long prickles extending from lower palisade layer of the rete ; h, blood- 
vessels of papillae ; i, bundles of connective-tissue fibres of pars papillaris ; k, section of spiral 
duct of coil-gland and sweat-pore. 



46 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

of the coil-gland below to the outermost stratum of the epidermis 
above. It has no other wall than that formed by the cells of the 
prickle-layer below and of the other layers of the epidermis, which 
successively surround this canal, narrow below and funnel-shaped 
above. Hence the lumen of the sweat-pore, if such a term be per- 
missible, is in free communication with the juice-spaces of the epi- 
dermis. 

The secretion of the coil-glands consists largely of globules of fat 
and granules of pigment. Their function, therefore, is plainly the 
lubrication of the skin with unguent, a task performed only in small 
part by the sebaceous glands, and by them chiefly for the pilary 
covering of the body. The palms of the hands and the soles of the 
feet, where no sebaceous glands exist, are thus lubricated with fat 
by the coil-glands. 

The total number of the coil-glands in the body is estimated to be 
between two and three millions, and the total length of the uncoiled 
glands about eight miles. These figures serve to give an approximate 
idea of their very great physiological importance, and of the extent 
to which violation of the rules of hygiene possesses interest from the 
pathological point of view. 

The function of the sweat-pores, which communicate directly with 
the excretory duct of the coil-glands, is distinct from that of the coil- 
glands, since it provides for the transmission outward of the watery 
fluids of the skin. The channel described as the sweat-pore is in 
ample and free communication with the intercellular spaces of the 
epidermis ; and this anatomical peculiarity provides fully for all the 
needs of evaporation at the surface of the body. 

The sweat excreted by the body differs under varying conditions 
of temperature, humidity of the air, and the amount and character 
of the articles ingested by the individual, either as food, drink, or 
medicament. Nearly ninety-eight per cent, of the secretion is pure 
water, the remaining proportions representing the saline constituents 
of the other fluids furnished by the animal in life. In all chemical 
analyses of the sweat, a source of error lies in the difficulty of securing 
the fluid secretion unmingled with that produced by the sebaceous 
glands ; and the same, it may be said in passing, is true of the chem- 
ical analysis of the sebum. According to Duhring, the iodide of 
potassium, benzoin, succinic and tartaric acids may be excreted with 
the perspiration. 

Unna, following in the line first indicated by Meissner, asserts that 
the coil-glands actually produce the subcutaneous fat-cushion ; and 
the anatomical basis of such a statement is clear. The coil-glands 
and the fat-cushion appear at the same period of foetal life and 
develop in the same proportions. At birth the clusters of fat are 
most conspicuous where the coil-glands are most numerous. In the 
adult the greater number of coil-glands are subcutaneous in situation 
and are closely surrounded by fat tissue ; while those glands which 
do not descend below the corium, though not thus surrounded, are 
regularly met by columns of fat advancing toward them from below. 



COIL-GLANDS. 



47 



The credit of discoveriDg and naming these fat-columns belongs 
to Dr. J. Collins Warren, of Boston, whose studies were principally 
directed to the anatomy of the thick cutis vera, 1 The back and 
shoulders of a vigorous adult furnish an integument much thicker 
than the hide of many pachydermatous animals. The papillae are 
imperfectly formed, and are represented by an undulating line. The 
follicles of the lanugo hairs penetrate only the superficial layers of 
the cutis. From the bases of the hair- follicles, nearly vertical clefts, 
or slender, columnar-shaped spaces, extend obliquely to the pan- 
niculus adiposus, which were fitly termed by Warren, " fat-columns 
or fat-canals," as thev are entirely occupied by adipose tissue. 
(See Figs. 3 and 4.) 



Fig. 20. 




Thin section of the skin of the fmger removed at the site 01 a sweat-pore. Magnified 150 
diameters. The cavities or spaces seen in the epidermis are, some, apparently uncolored ; 
others are blackened by the action of osmic acid upon fat originally contained in either cells 
or spaces between the latter. The effect is due to excretion of fat by the coil-glands, and the 
condition shown is not exhibited in all sections of the skin made at the same level. It is 
probably transitory and most apparent when the skin is macerated by sweat. 

These columns are about four mm. in length, and are slightly 
wider than the hair-follicles above. Their long axes form a slight 
angle with that of the follicle, but they are nearly parallel to that of 
the erector pili muscle Two horizontal prolongations are given otY 
on either side of the middle of this axis, partly iat-filled. Near this 
point Dr. Warren called attention to " the coil of a sweat-gland, held 
in place by a few delicate fibres." The duct of the gland runs to 
the top of this space, whence it may be traced to the side of the hair- 
follicle. The connective-tissue fibres seem to terminate abruptly at 
the edges of these columns. The cleft slightly w r idens below, and on 
the side toward which its axis leans the fibres of connective tissue 
form a bundle penetrating below to the subcutaneous fat. The 



1 Satterthwaite's Manual of Histology, p. 420. New York, 1SS1. 



48 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

erector pili muscle is inserted partly into the base of the follicle and 
partly into the apex of the fat-canal. 

These columns correspond in number to the hairs. The blood- 
vessels which they contain, springing from the subcutaneous plexus, 
bifurcate at the lateral clefts. 

The later studies of Unna demonstrate very clearly that the fat- 
columns, first recognized by Warren, invariably advance toward the 
coil-glands, the latter either singly or in groups ; and that the con- 
nection of the fat-columns with the hair- follicles is a mere incident 
of that advance. 

The alternation of muscular fibres with the secretory cells of the 
duct of the coil-gland is a provision for the extrusion of the gland- 
secretion onward. The same anatomical arrangement permits free 
communication between the epithelia and the lymph-spaces which 
reach into the connective-tissue sheath of the gland. As a result, 
the lymph flows freely among the secreting elements of the gland 
and its duct. This lymph, loaded with fat, streams away from the 
coils, and before it reaches the lymphatic trunks its fat-globules are 
filtered away in the subcutaneous tissue. 



The Odorous Emanations from the Skin. 

The skin of the human body in health is the constant source of 
odorous emanations, which, in pathological conditions, may be greatly 
increased or otherwise changed. The nature and exact sources of 
these emanations are as yet imperfectly understood. Were these ex- 
clusively of a volatile, gaseous, or vaporous composition, even though 
such fluids were capable of condensation upon external bodies, this 
could scarcely explain the well-known fact that some of the lower 
animals are capable of tracing the track of the human being for miles 
over a wind-swept path, till the soil pressed by the foot is covered 
with water. There is strong reason to believe that these emanations 
are vehicles by which certain contagious and infectious diseases are 
communicated from one individual to another. They at times con- 
tain living matter derived from the protoplasm of the body, and are 
capable of conveying bacteria in compact masses and enormous quan- 
tities through the atmosphere when agitated by a current of air. 
Some of the schizomycetes weigh but one-ten-billionth of a milli- 
gramme, and are transported through space in the most attenuated 
of media. These emanations are properly regarded as having their 
origin in the secreting system of the skin, but in what proportion the 
several secreting glands participate in the product it is difficult to 
establish. The sweat at times, even to human nostrils, exhales a 
distinct odor, though, as before indicated, to what extent this is due 
to its admixture with the sebaceous material it is difficult to deter- 
mine. Peculiarly fetid and disgusting odors occasionally originate in 
chemically altered sebum, where the influence of the sweat secretion 
must be, from the locality under examination, partly eliminated. 



THE NAILS. 



49 



The Nails. 

Nails are dense, elastic, and translucent concavo-convex plates, or 
shells of horny tissue, placed upon the dorsum of the terminal ex- 
tremities of the distal phalanges of the fingers and toes. Each has a 
free border at the distal portion of the pulp of the digit, with sides 
and proximal borders let into distinct furrows of the skin. The 
convex surface of the nail is exposed, the concave regarding the 
phalanx, and implanted upon the nail-bed beneath. 

In the embryo the first change looking to the future formation of 
a nail consists in a peculiar smoothness and brilliancy of the epidermis 
covering the dorsum of the distal phalanges. Later, an epithelial 
ridge or line with a groove in front of it traverses the tip of the 
finger. Thus, three regions are defined : that behind the ridge, the 
nail-wall ; that in the groove, the nail-bed • and that in front of the 



Fig. 21. 



& ,. ¥ 




Vertical section of one-half of nail and matrix, a, nail substance ; b, horny layer ; c, mucous 
layer ; d, papillae of corium ; e, nail furrow destitute of papillae ; /, horny layer of the ungual 
furrow rising above the nail ; g, papillae of skin of dorsal surface of the finger. 



groove, the pulp of the last phalanx of the digit. A collection of 
large prickle-cells at the orifice of the nail-fold soon furnishes the 
first trace of the rudimentary nail. Mature nail-cells finally push 
forward between the prickle and horny layers of the nail-bed, which, 
by fan-shaped bundles of follicles, is firmly united to the periosteum 
of the phalanx. Lastly, a thin plate of horny material with a free 
edge, is visible externally in the fingers and toes of the newborn 
child. 

In the adult, what is termed the matrix of the nail, is the tissue 
from which the horny plate springs. It is separated, as shown by 
Hans Hebra, into, first, a posterior part, filled with from three to 
six rows of papillae. Next, in advance of this, is a lenticular space 
with curved borders, the anterior limit of which corresponds to the 
anterior border of the lunula. The area included in these two divi- 
sions is provided with papillse grouped in symmetrically converging 

4 



50 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



ridges, decreasing in size as they pass forward. This forms the 
matrix of the nail. Further forward, the nail-bed proper — in other 
words, the tissue that supports, rather than produces the horny plate 
— is composed of higher ridges of papillae whose grooves and sum- 
mits are covered with prickle-cells, and whose height is uniformly 
maintained as they stretch forward toward the pulp of the finger. 

Attention has been already called to the fact that the digital 
arteries communicate directly with venous spaces and veins in the 
nail-bed, an anatomical peculiarity demonstrated by Hoyer. This 
arrangement evidently provides for the safety of these slender and 
exposed organs in conditions arresting temporarily either the venous 
or the arterial current. 

The Nail, or, as it is termed by Unna, the true nail or nail- 
plate, originates only from the floor of the nail-fold as far forward 
as the anterior edge of the lunula. As to its formation, it may, 



Fig. 22. 




Implantation of the nail at its border. P, papillae decreasing in size toward the middle line ; 
E, rete mucosum, which broadens toward the border of the nail, and forms irregular pro- 
longations ; R, E, epidermal layer; N, plate of the nail. Magnified 500 diameters. (After 
Heitzmann.) 

therefore, be imagined as springing from its matrix vertically in the 
form of an involuted, shield-shaped plate, its convexity regarding 
the proximal phalanx. It may then be viewed as pressed downward 
over its nail-bed in front, with partially unfolded edges enwrapped 
by the epidermis of the sides, the narrowed point of the shield, 
elongated when untrimmed, projecting at some distance beyond the 
tip of the finger. 

With this conception, it is easy to understand that the nail is 
constituted of horny filaments, or coherent strata of cornified cells, 
passing from the matrix or floor of the nail-fold. The upper surface 



THE NAILS. 51 

of the nail grows, therefore, from the bottom of the nail-fold ; the 
under surface from the lunula ; and the intermediate layers propor- 
tionately from the parts between. It is firmly attached to the nail- 
bed by ridges upon its under surface, which interlock with corre- 
sponding grooves on the upper face of the bed. 

The Nail-fold, crescentic in shape, clasps the nail posteriorly 
and at the sides. It is formed of connective tissue, whose bundles 
are interpenetrated by numerous coil-glands and fat-columns. The 
epidermis beneath the nail exhibits prickle, granular, and horny 
layers. As the nail is gradually liberated from its bed, both at the 
sides and point, the cornification of the horny layer becomes more 
complete, so that finally, as the nail-plate is pushed forward, it no 
longer rides over the cells of the rete, but over a completely cornified 
tissue. 

If the pulp of any nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the sur- 
face of the nail, just behind its free border, a whitish and yellowish 
band, convex anteriorly and somewhat increasing in width laterally. 
This line is also visible when no pressure is exerted upon the digit, 
its width varying under the conditions described. This border 
represents the space in which the three layers of the epidermis from 
the skin of the point of the finger, viz., the horny, the granular, and 
the prickle-layer, successively come in contact with the under surface 
of the nail. 

The lunula is the relatively light-colored space extending from the 
middle part of the nail-fold posteriorly to its well-defined convex 
border in front. After artificial removal of the nail-fold, it is seen 
to extend to the posterior and enclosed border of the nail-plate. It, 
therefore, represents that part of the matrix of the nail which is not 
concealed by the nail-fold. Its color is not due to absence of vas- 
cularity, but solely to opacity of the keratogenous, cells (Ranvier) 
which are concerned in the production of the horny threads that 
form the nail. 



52 GENERAL SYMPTOMATOLOGY. 



II. 

GENERAL SYMPTOMATOLOGY. 

In cutaneous, as in other diseases, the clinical signs or symptoms 
of the morbid process are those by which it is recognized alike by 
the patient and the physician. These are divided into subjective and 
objective : the former, those appreciated by the patient alone in 
consequence of his sensations ; the latter, by the eye and the touch of 
another who undertakes the investigation of the disease. It should 
be remembered, however — and this is a matter of some importance 
in this connection — that many objective signs are made manifest to 
the eye and touch of the patient himself, and liable to be interpreted 
or misinterpreted by him, with consequences which should not be 
ignored. 

Subjective Symptoms. — The purely subjective symptoms of a 
disease of the skin are those manifested to the patient by sensations 
other than those connected with vision and his own sense of touch. 
They include sensations of itching, smarting, tingling, pricking, and 
burning ; sensations as of increased or diminished susceptibility to 
the contact of foreign bodies ; of increased or diminished tempera- 
ture; pain in various grades of severity; and disordered sensations, 
as of the crawling of insects over the part, currents of hot or cold 
vapors or liquids, and compression of portions of the skin by either 
cords, bands, or closely fitting plates The character of the subjective 
sensations experienced by a patient often proves an aid to the physi- 
cian in recognizing the nature, not merely of a present disease, but 
of one also which has preceded. Thus the sensation produced by an 
attack of erysipelas is rarely an itching, while the latter is highly 
characteristic of eczema and scabies ; the pain of zoster and the 
tingling of urticaria being distinctly different, not only from each 
other, but from the subjective symptoms named above. 

Objective Symptoms. — The study of the objective symptoms of 
a cutaneous disease is of paramount importance. In no respect does 
the skilled physician so distinguish himself from one who is inexpert 
as in the recognition of the typical or atypical objective characters 
presented in diseases of the skin. The study is one which can be 
neglected safely by no diagnostician, and its rewards are precious in 
every department of medical science. These symptoms are spread 
before the eye, and their legibility increases with every hour of 
careful attention. 

These signs of skin disease — or, more literally, skin injury — are 
called lesions, and it is usual to classify them as primary and second- 



ELEMENTARY LESIONS. 53 

ary. Such a division is, however, open to criticism, since, in point 
of time merely, some of the so-called primary lesions of the skin 
become in turn secondary and even tertiary. Thus a papule which 
might at one moment be called primary, may be transformed wholly 
or in part into a vesicle, which thus becomes a secondary lesion ; and 
such vesicle again, in the evolution of a disease, may become a ter- 
tiary pustule. The latter finally may result in a quaternary crust. 
In the following pages these symptoms of skin disease are distin- 
guished as elementary and consecutive. 



Elementary Lesions. 

In describing the average size of cutaneous lesions, it is less con- 
venient to state their measurement in fractions of a line or millimetre 
than to convey an approximate idea by a comparison with familiar 
objects of relatively fixed dimensions. The objects usually selected 
for this purpose are, beginning with the smallest, the seeds of poppy, 
mustard, and rape ; the coffee-bean ; the pea ; the beau ; the cherry ; 
the finger-nail ; the chestnut ; the horse-chestnut ; the egg of the hen 
and of the goose ; and the orange. To these may also be added the 
point and the head of a pin. The student will find it useful to 
familiarize himself with the size of the small seeds mentioned, that 
their names may at once suggest to him the relative size of the 
lesions to which they are compared. 

Macule, Spots, or Stains, are generally circumscribed 
alterations in the color of the integument, differing as 
to the size, shape, hue, and duration of the dyschromia, 
and unaccompanied by elevation or depression of the 

SURFACE. 

Maculae may be due to arterial or venous hyperemia, to the escape 
of the coloring matters of the blood into the skin, to acquired and 
congenital telangiectases, and to pigment anomalies. 

Examples of maculae are to be found in the exanthematous rashes 
(measles) ; in localized hyperaemiee of the capillary plexus of the 
corium, disappearing in various degrees according to the pressure 
exerted on the part (rosacea) ; in visible acquired development of 
bloodvessels in the skin (telangiectasis) ; in congenital vascularization 
of the surface (naevi) ; in variously colored blood extravasations and 
stases (purpura) ; in stains produced by contact with dyes (hand- 
workers in aniline) ; and in pigmentary changes such as those pro- 
duced by solar heat (freckles), or by leprosy. 

Extensive non-circumscribed changes in the skin color are seen in 
the course of several general disturbances of the economy, as in 
yellow fever, cancer, chlorosis, albinism, Addison's disease, argyria, 
and icterus. 

Spots of various color and device are also produced by the inten- 
tional or accidental introduction of pigmented particles beneath the 



54 GENERAL SYMPTOMATOLOGY. 

epidermis, as by the process of tatooing, the explosion of gunpowder, 
etc. 

Maculae exhibit a wide variation in color from a rosy pink to a 
chocolate-brown or even a black. This diiFereuce has suggested the 
employment of such descriptive terms as roseola, erythema, and pur- 
pura, which have, unfortunately, served to distinguish both features 
of diseases and diseases themselves. 

A macula which encircles another lesion, as, for example, the halo 
around the vaccine vesicle, is called an areola. Linear hemorrhagic 
streaks are called vi bices; punctate and larger extravasations of 
blood are termed petechia? and ecchymoses. 

PAPULiE, or Papules, are solid or compressible, ephem- 
eral OR PERSISTENT, circumscribed projections from the 

SURFACE OF THE SKIN, VARYING IN SIZE FROM A POPPY-SEED 
TO A COFFEE-BEAN. 

These exceedingly common skin symptoms vary greatly in their 
shape, color, location, career, and significance. Thus they may be 
flattened at the apex, acuminate or pointed, conical, rounded, or 
depressed at the summit to form an umbilication. They may be 
pale, rosy, dark or lurid-red, purplish, or even blackish. They may 
develop in transitory or persisteut processes ; they may be trans- 
formed into lesions containing fluids ; may desiccate and furnish 
scales either at apex or base ; may degenerate into ulcers ; or enlarge 
into tubercles or tumors. They may be scratched, torn, or rubbed 
so as to lose their typical appearance ; they may come and go ; be 
sensitive to sudden changes in the blood -current, and yet be them- 
selves persistent. 

The mixed forms described above are generally named vesico- 
papular or papulo-vesicular, papulo- squamous, papulo- pustular, 
lesions, etc. 

Lesions which simulate the papule and which, though described 
under that title, really belong to another category, are the small, 
semi-solid elevations of the surface which form at the orifices of the 
ducts of the cutaneous glands and follicles. Thus they may consist 
of little heaps of epidermis about the hair-follicles (lichen pilaris, 
keratosis pilaris), or of inspissated sebum collected in one or all of 
the acini of the sebaceous glands (milium, comedo). 

The concomitants of an eruption of papular type also vary. Thus 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo) ; or itching of the most in- 
tolerable character (eczema papillosum) ; or production of trifling 
sensations of annoyance, as a slight burning without other subjective 
symptoms (acne, lichen planus). 

Papules which are transformed into moist lesions become covered 
with a crust. Papules which are scratched or torn by the finger- 
nails usually betray the fact in the minute and flat blood-scale dried 
upon their surface. Papules which ulcerate may be followed by 






ELEMENTARY LESIONS. 55 

scars. Papules which have undergone the process of involution may 
be followed by macular sequel se. 

Pomphi, Urticle, or Wheals are more or less transitory, 
rosy-red and whitish, irregularly shaped and sized eleva- 
tions of the surface of the skin, produced by blood-stasis 
in spasm of the vessels, accompanied by a tingling or 
pricking sensation, and characterized by rapidity of evo- 
lution and frequency of recurrence. 

The typical wheal is seen in the disease known as the nettle-rash 
(urticaria), where closely packed, shining, roundish and whitish, pea- 
to finger-nail-sized elevations of the skin are visible, surrounded by 
a slightly rosy border. They are firm to the touch, and arranged in 
patches, circles, bands, gyrations or striations, often disappearing in 
a brief time and recurring with or without a renewal of the cause. 
They are occasioned by a rapid exudation of serum into the rete or 
pars papillaris of the corium. This is supposed to be due to clonic 
vascular spasm, producing irregularities in the lumen of the skin 
capillaries, under the influence of the vasomotor nerves which supply 
a small area of the superior pars vascularis of the derma. The sen- 
sations produced by the wheal are particularly stinging, burning, 
pricking, and itching. They are often surrounded by an areola. 

"Giant" wheals are such as enlarge to the dimensions of an egg 
or a tomato, or cover extensive areas of integument, as, for example, 
the entire surface of the buttock or shoulder. 

Relics of disappeared wheals are usually transitory erythematous 
macula?, but in rare cases a more or less deep pigmentation is left, 
which slowly disappears (urticaria pigmentosa). 

It should be borne in mind that at times the wheal-like condition 
is assumed by papilla?, as also by lesions resulting from such trauma- 
tism as the bites of insects, reptiles, horses, dogs, etc. 

TUBERCULA, OR TUBERCLES, ARE CIRCUMSCRIBED, SOLID, GEN- 
ERALLY INCOMPRESSIBLE, AND PERSISTENT, NODOSITIES OF THE 
SKIN, VARYING IN SIZE FROM A COFFEE-BEAN TO A CHERRY. 

They may be largely projected from the free surface of the integu- 
ment, or be deeply seated in the skin, and but a small portion become 
evident to the view externally. Their varieties as to shape, color, 
size, and other features, correspond in great part to those described 
in connection with papules. They may be attached by a broad base 
to the skin, or be pedunculated, or even pendulous. Their seat is 
usually in the deeper portions of the corium or the subcutaneous 
connective tissue. Degenerating aud ulcerating tubercles are fol- 
lowed, as might be supposed in view of their volume, by considerable 
destruction of tissue, and in cases of repair by correspondingly ex- 
tensive cicatrices. Tubercles are seen in such diseases as fibroma, 
molluscum epitheliale, syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules ; but the 
distinction between these two forms of lesion will be better recog- 



56 GENERAL SYMPTOMATOLOGY. 

nized when attention is paid to the particular portion of the skin in 
which each takes its origin. Papules spring oftenest from the super- 
ficial layers of the derma ; tubercles, on the other hand, from the 
deeper. This being remembered, it will be clear that at times a 
tubercle may project from the surface to a less extent than a papule, 
though its larger volume is evident as soon as the skin within which 
it has developed is handled. 

Tubercles due to a cellular infiltration may cease to be circum- 
scribed, and by coalescence furnish a diffuse involvement of both the 
skin and subcutaneous tissue. 

Phymata, Tumores, or Tumors, are masses of solid 

3r less commingled with 
differing in size, shape, 
color, and in the benignity or malignity of their career, 
either located within or beneath the skin, or, being 
attached to the latter, projecting from it to a variable 

EXTENT. 

The mere fact that a lesion of the skin approaches in dimensions 
the size of a tumor is in itself an element of gravity. Tumors may 
originate in mere hyperplasia of the living matter ; may consist of 
new formations of greater or less danger to the vicinage, or the gen- 
eral economy ; may be formed of blood or lymphatic vessels, or both 
in the same lesion ; may embody large fluid-containing cysts ; may 
be built up of nervous tissue, fat, bundles of connective- tissue fibres, 
glandular elements, and indeed of any of the elements which exist 
physiologically in the human integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

Vesiculje, or Vesicles, are elevations of the horny 
layer of the epidermis with limpid, lactescent, or san- 
guinolent fluid contents, varying in size from a poppy- 
seed to a coffee-bean. 

Typical vesicles are seen in the minute and transitory lesions 
occurring in the vesicular form of eczema. They are usually filled 
with a clear serum. Variations from this type are, however, com- 
mon. Thus, they may be flattened, acuminate, roundish, umbili- 
cated, or conical ; may be fully distended or partially collapsed upon 
their contents ; may have a short or long duration ; may be distended 
with milky, chylous, or a blood-stained fluid ; may be opalescent, 
yellowish, reddish, or blackish in color ; several may coalesce to form 
a many-chambered lesion ; and a single one or several such may 
undergo transformation into pustules or bulla?. Vesicles may termi- 
nate by accidental or spontaneous rupture, their contents freely flow- 
ing forth upon the surface of the peripheral integument ; or they 
may desiccate to a crust ; or may even terminate by one of the ulcer- 
ative processes. They may or may not be accompanied by pruritus. 
Minute vesicles, which are merely the external apices of large-cham- 



ELEMENTARY LESIONS. 57 

bered accumulations of fluid beneath, occasionally form upon the 
surface of the skin. 

Such are seen in the course of lymphangiectasis. 

PustultE, or Pustules, are circumscribed cutaneous ab- 
scesses, COVERED WITH AN EPIDERMAL ROOF-WALL, AND VARY- 
ING IN SIZE FROM A MILLET-SEED TO A FILBERT. 

The typical pustule contains pus, and is colored yellowish, yel- 
lowish-green, or brownish-green, according to the admixture of its 
contents with blood. The pus, being an inflammatory product, 
necessarily indicates the occurrence, at the base of the pustule, of an 
inflammatory process. Pustules, like vesicles, may be roundish, 
acuminate, globoid, couical, umbilicated, surrounded by an inflamed 
or normal integument; may be superficially or deeply seated; may 
terminate by rupture or desiccation ; may or may not be followed by 
an ulcer and ultimate cicatrix. They may be seated either upon the 
free surface of the skin, or at an orifice of a follicle, in which case 
they represent au inflammation with purulent product in the duct or 
gland beneath. 

Pustules may originate as such ; or as a consequence of trans- 
formation of vesicles ; or after a change in a papule, which may thus 
come to have a purulent apex. According to Auspitz, they invari- 
ably originate from vesicles. Pustules often result in the formation 
of crusts, the latter varying in color according as the pustules from 
which they originated contained a clear serum or blood. 

Transitional forms between vesicles and pustules are termed vesico- 
pustules. Pustules of a large size and resting upon an indurated, 
engorged, and elevated base are often called ecthymatous. 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and 
many other cutaneous diseases, including several forms of dermatitis 
medicamentosa. They all contain pus cocci. 

BulltE, or Blebs, are superficial or deep-seated eleva- 
tions OF THE SKIN HAVING FLUID CONTENTS, DIFFERING IN 
COLOR, SHAPE, AND CAREER, AND VARYING IN SIZE FROM A 
COFFEE-BEAN TO A GOOSE'S EGG. 

Blebs have been described as large vesicles ; but this fails to define 
exactly their pathological character. Like vesicles they may contain 
serum, lymph, blood, or pus ; and be variously colored in the degrees 
according to which their contents become visible through a semi- 
transparent roof- wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, conical, and even exhibit angles. They 
may be seated upon an apparently unaltered or evidently morbid 
integument ; and may or may not present a peripheral areola. 

Bullae may persist or rupture ; may desiccate or degenerate into 
ulcers ; may collapse after the escape of their contents, and the roof- 
wall become glued to the base from which it was originally raised. 

Bullae usually occur in extremely debilitated states of the system, 
and are, as a rule, of graver portent than other fluid-containing 



58 GENERAL SYMPTOMATOLOGY. 

lesions of the skin. They occur in scalds and burns, in pemphigus, 
leprosy, erysipelas, syphilis, and moist gangrene. 



Consecutive Lesions. 

Squama, or Scales, are attached or exfoliated epithe- 
lial LAMELLAE, WHICH HAVE BECOME APPRECIABLE AT THE 
SURFACE AS THE RESULT OF SOME MORBID PROCESS IN THE SKIN. 

A physiological desquamation is constantly in progress over the 
superficies of the body, whose evidences are not pronounced in skins 
properly cleansed by ablution. In morbid processes, however, de- 
squamation may occur as a distinct symptom in various forms. Thus 
the scales may be minute, fine, branny, dirty- white, or yellowish ; 
they may be larger, pearly-white, shining ; dry or fatty ; aggregated 
so as to resemble flaky pie-crust ; exfoliating in extensive sheets, as 
from the entire sole of the foot or palm of the hand; or in glove- 
finger-like sheaths, as from the surface of a digit. They may be 
scanty, scarcely perceptible, and so attached as to require force for 
their removal; they may fall spontaneously in a pulverulent shower, 
being so abundant as to fill the garments or bed-clothing of the 
patient. 

Furfuraceous desquamation is that form in which fine bran-like 
scales are shed from the surface. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, 
and in several of the parasitic diseases of the skin. 

Scales are frequently intermingled with other lesions ; often they 
succeed the latter. Thus a papule may scale at its apex, or surround 
its base with a collarette of loosened epidermal plates, beneath or 
between which a macular stain is visible. Again, they may develop 
from the macule, the tubercle, or the tumor. Though generally con- 
ceded to be evidences of a dry and non-discharging disease of the 
skin, they are at times accompanied or succeeded by moisture of the 
part affected. 

The term u scales " is sometimes applied to the flattened plates of 
dried sebum which form on the scalp and portions of the trunk in 
seborrhoea sicca. 

Crusts, or Crusts, upon the skin, are relics of the 
desiccation of its pathological products. 

Crusts never occur as primary symptoms of disease. When formed 
by the desiccation of serum only they are of a yellowish, straw- 
yellowish, or reddish-yellow hue ; when composed largely of dried 
pus they are colored greenish, or greenish-yellow ; and, when there 
has been an admixture of blood, they are usually brownish or 
blackish. At times they suggest in appearance gum, honey, or 
Venice turpentine ; in shape they may have the form of the concavo- 
convex lid of a watch-case ; in color and shape they may resemble 
the half-shell of the oyster, or the carapace of a small turtle. They 



CONSECUTIVE LESIONS. 59 

may be delicate and thin ; bulky and thick ; friable or mealy ; may 
be firmly attached to the subjacent tissues, or readily separable ; may 
cover a sound, though tender and reddened epidermis ; may conceal 
a superficial, or deep, foul-based ulcer, by whose secretions from 
beneath they are raised above the plane of the skin and increased in 
thickness. They may be circumscribed and no larger than a small 
finger-nail ; may envelop an entire limb or organ, as the leg or the 
penis ; or, finally, may be so irregularly disposed among other lesions, 
papules, pustules, excoriations, and open ulcers, that it is difficult to 
define their outline, and even to recognize their identity. Crusts 
formed of dried sebum are greasy to the touch, dirty -yellowish in 
shade, and usually seated upon a non-infiltrated base. Crusts are 
common in eczema, syphilis, leprosy, seborrhoea, and a large number 
of other diseases of the integument. 

Excoriations are superficial solutions of continuity, 
usually involving portions of the skin affected with 
pruritus, and resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin lesions, 
possess a value from the diagnostic standpoint which can scarcely be 
overestimated. They occur as striated, linear, punctate, circular, or 
irregularly shaped, furrowed wounds, at times involving areas of 
flat surface, oozing with serum or blood, covered with dried blood or 
crusts, yellowish or reddish in hue, and for the most part both in- 
duced and accompanied by severe pruritus. They may coexist with 
hypersemia and infiltration of the skin beneath, brought on by the 
irritative character of the continuous, or, more frequently, interrupted 
cause by which they were begotten. 

Excoriations become significant according as they indicate scratch- 
ing, tearing, or other species of wounding by the finger-nails, and 
rubbing portions of the integument with foreign bodies. In the 
former case they are significantly recognized in those portions of the 
body most accessible to the hands, though in the case of eczematous 
children and infants they may originate by the rubbing together of 
the knees ; or the leg of one side by the feet and toes of the other. 
The loss of tissue may extend deeper than the rete — at times invad- 
ing the papillae of the corium, which bleed in consequence. 

Excoriations may occur without the appearance of other lesions, as 
in the disease called pruritus ; but where itching is severe and induced 
by a cutaneous exanthem, the lesions constituting the latter may be 
intermingled with, obscured, or even obliterated by excoriations and 
the pathological processes to which they give origin. Thus macules, 
vesicles, pustules, and papules may undergo change ; and the recog- 
nition of the type of the existing disease be correspondingly difficult. 
Excoriations are common in skins wounded by lice, bed-bugs, and 
gnats ; in the subjects of eczema, scabies, intertrigo, and prurigo ; 
and in individuals with special sensitiveness of the integument to the 
action of a medicament employed either internally or externally. 



60 GENERAL SYMPTOMATOLOGY. 

Rhagades, or Fissures, are linear solutions of con- 
tinuity, USUALLY OCCURRING IN PREVIOUSLY INFILTRATED 
PORTIONS OF THE SKIN. 

They may extend to the derma, and even invade yet deeper 
structures ; may be painful, or the reverse ; dry, secretory, or iu- 
crusted ; are often hemorrhagic, and usually formed with sharply cut 
walls. They are of frequent occurrence in the vicinity of the articu- 
lations, in which situations they are induced or aggravated by the 
joint-movement stretching or tearing tissues whose extensibility has 
been diminished by any morbid process. Fissures may terminate in 
ulceration. They vary as to length, curve, and tenderness. They 
are often exquisitely painful, and greatly complicate the skin disease 
in which they occur. They may follow the curve traced by the 
boundaries of bodily organs near which they occur — as, for example, 
the line of the posterior junction of the ear with the head, or of the 
breast of a woman with the thoracic wall where it rests. Fissures 
occur in eczema, syphilis, dermatitis, and lichen ruber. 

Ulcer a, or Ulcers, are losses of substance resulting 
from a previous pathological process involving the 

CORIUM, AND, IN CASES, THE SUBCUTANEOUS TISSUE. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics Every ulcer has an 
outline, base, floor, edges, and secretion. The outline may be cir- 
cular, crescentic, reniform, ovoid, serpiginous, or with horseshoe-like 
contour. The base, or underlying tissue, may be soft, supple, indu- 
rated, or in a state of active inflammation, with consequent infiltra- 
tion. The floor may be glazed, shallow, deep, excavated, cup- or 
funnel-shaped, " worm-eaten/' crateriform, sloughy, covered with a 
tenacious or readily removed secretion, granular, puriform, or hemor- 
rhagic. The edges may be clean-cut, having a punched appearance, 
undermined, everted, ragged, irregular, or contracting, with a whitish 
inner border of advancing cicatrization. The secretion may be scanty, 
limpid, puriform, profuse, ichorous, and odorless, or exhaling an 
offensive stench. They may be so crust-covered as to be invisible, 
or so exposed and erosive in action as to render the affected suface in 
the highest degree unsightly. They may be acute or chronic, insen- 
sitive or productive of intense pain ; may heal by cicatrization, 
remain open for a lifetime, or prove fatal by either destruction of 
parts essential to life, or by exhaustion of the vital forces. 

Cicatrices, or Scars, are new-formed substitutes for 
lost connective tissue. 

Scars never succeed excoriations, fissures, or other solutions of 
continuity in the skin, which have not penetrated as far as the derma, 
and resulted in destruction of a portion of the elements of which the 
latter is built up. They possess the highest importance for the 
diagnostician, since they point invariably to a pathological process 
whose career is terminated, the characteristic features of which they 



CONSECUTIVE LESIONS. 61 

frequently embody. They may be regarded as the special and per- 
sistent imprints upon the integument of the serious disorders from 
which it has suffered. 

To a certain extent, as already shown, scars retain traces of the 
special peculiarities of the lesions, and even of the diseases, which 
they succeed. The identification, however, of the individual prede- 
cessor in each instance is, in the present state of our knowledge, not 
always possible from a study of cicatrices alone. The extent of 
knowledge in this direction is, however, rapidly increasing ; and in 
many cases the certainty thus acquired is of incalculable value to the 
diagnostician. 

Scars are remarkable for their tendency to contraction and gradual 
decoloration. They may be minute, punctate, extensive in area, 
attached to underlying tissues, depressed, raised above the plane of 
the peripheral skin, seamed with furrows, pliable and soft, indurated, 
traversed by ridges, knotted, and as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular 
prolongations toward contiguous portions of the skin, and by subse- 
quent contraction induce considerable distortion and deformity. Thus 
they may drag down an eyelid, and ectropion ensue ; may glue the 
lobe of the ear to the cheek ; may evert lip or nostril. When recent, 
they are usually reddish in tint ; when older, be pigmented in centre 
or circumference ; or, as is common, exhibit a gradual decoloration, 
centrifugal in its progress. They may be the seat of pain from an 
entrapped nerve-filament ; may reopen to ulceration ; or be accom- 
panied by no subjective sensation. Not rarely they become the 
origin of the disease known as cicatricial keloid. Scars are unpro- 
vided with hairs, papilla?, or the orifices of sweat-pores and sebaceous 
gland ducts. As implied in the definition given above, scars may 
result from any disease or injury of the skin which involves loss 
of connective-tissue elements in the corium. 

To the several lesions defined above Bazin adds, as elementary 
forms, the mucous patch of syphilis ; the cuniculus, or furrow, pro- 
duced in the skin by the acarus scabiei ; and the sulphur-colored 
crusts of favus. These, however, are not general, but special 
features of individual disorders, and are best studied in connection 
with the latter. 

The elementary lesions of the skin are termed by Auspitz, "an- 
themata ; n groups of such lesions, " synanthemata ; " and, as in 
accordance with common usage, generalized eruptions affecting the 
entire surface of the body, " exanthemata." The word " erythan- 
thema " is used by this writer to describe groups composed of several 
of the elementary lesions of the skin, as, for example, of papules, 
vesicles, and pustules rising from a common, reddened, and hyper- 
aBmic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in quali- 



62 GENERAL SYMPTOMATOLOGY. 

fying terms, which here require definition. They relate chiefly to 
the color, shape, distribution, and method or period of evolution of 
lesions as they are observed in individual cases. The more impor- 
tant of these terms, as used by modern writers, are arranged below, 
alphabetically, with a brief explanation appended to each. A much 
larger list of obsolete adjectives, employed by older authors, is pur- 
posely omitted. 

Abdominalis. Located on the abdominal surface. 

Acquisitus. Acquired. 

Acuminatus. Having a pointed apex. 

Acutus. Of acute course. 

Adultorum. Occurring in adult years. 

aestivalis. Occurring in the season of summer. 

Aggregatus. Collected in patches. 

Agrius. Acute, or angry in appearance. 

Albidus. Of whitish color. 

Angiectaticus Vascularized. 

Annularis. In the form of a ring. 

Annulatus. In the form of a ring. 

Apyreticus. Unaccompanied by fever. 

Areatus. Occurring in areas. 

Artificialis. Producible artificially. 

Asymmetricalis. Of different distribution on the two lateral halves of the body. 

Autumnalis Occurring in the fall of the year 

Brachialis. Occurring on the surface of the arm. 

Cachecticorttm. Occurring in debilitated subjects. 

Capitis. Occurring on the head, usually the scalp. 

Cavernosus. Large chambered. 

Chronicus. Chronic in course. 

Circinatus. Of circular outline. 

Circumscriptus. Having a definite contour. 

Confertus. Arranged in close proximity, with coalescence of lesions. 

Confluens. Arranged in close proximity, with coalescence of lesions. 

Contagiosus Capable of communication by contagion. 

Corporis Occurring on the surface of the body ; employed usually to designate 
an eruption upon the trunk, as distinguished from that on the head or extremi- 
ties. 

Crustosus. Crusted. 

Crystallinus. Of crystalline appearance. 

Diffusus. Irregularly disposed. 

Discretus. Having isolated lesions. 

Disseminatus. Disseminate, without regularity of distribution. 

Eruption. Is used of the totality of all patches and lesions upon the person of 
one individual. 

Erythematosus Having a reddish blush. 

Essentialis. Idiopathic. 

Exfoliativus. Having a tendency to exfoliation or shedding from the surface of 
the body. 

Exulcerans. Is employed by French writers to designate superficial ulcerations, 
or lesions with a tendency to such a process By English and American authors 
it is sometimes used to designate unusually deep ulcerations. 

Facialis. Located on the face, usually as distinguished from the scalp. 

Favosa. Displaying crusts of favus 

Febrilis. Accompanied by a febrile process. 

Femoralis. Occurring on the surface of the thigh. 

Fibrosus. Composed of fibrous tissue. 

Figuratus. Having a figured appearance. 

Flavescens. Of yellowish hue. 

Foliaceus. Resembling a leaf or leaves. 

Follicularis. Concerning the cutaneous follicles. 

Fungoides. Resembling a fungus. 



DEFINITION OF TERMS. 63 

Furfuracees. Exhibiting numerous fine, bran-like scales. 

Guttatus. Of the size of a drop of water. 

Gyrates. Having a serpiginous or gyrate outline. This is usually the result of 
a coalescence of imperfect circles or semicircles. 

Herpetiformis. Vesicular or herpetic in type. 

Hiemalis. Occurring in the winter season. 

Hemidus. Accompanied by moisture. 

Hypertrophicus. Characterized by hypertrophy. 

Hystrix. Having lesions projected or erected like quills. 

Imbricates. With crusts or scales overlaid like tiles. 

Impetiginous. Pustular. 

Infantilis. Occurring in infancy. 

Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 

Labiaeis. Occurring upon the surface of the lip. 

Lenticttlaris. Of the size of a small bean. 

Lividus. Deeply colored. 

Maculosus. Discolored. 

Madidans. Characterized by moisture. 

Marginatus. Having a defined margin. 

Medicamentosus. Produced by external or (more commonly) internal medica- 
tion. 

Melanodes. Of blackish color. 

Miliaris. Of the size of a millet-seed. 

Metis. Of mild, benignant type — the reverse of agrius. 

Meltiformis. Exhibiting simultaneously several types of elementary lesions. 

Neonatorum Occurring in the newborn 

Neuroticus. Having nervous association. 

Nigricans. Of black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 

Nummularis. Of the size of small coins. 

Oleosus. Accompanied by an oily secretion. 

Palmaris. Occurring on the palms. 

Parasitarius. Produced by an animal or vegetable parasite. 

Parasiticus. Produced by an animal or vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 

Phlegmonoses. Accompanied by deep-seated inflammation. 

Phlyctjenoides. Characterized by groups of small vesicles. 

Pigmentosum. Accompanied by pigmentation. 

Pilaris. Belated to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous, This is the Greek equivalent of the Latin multiform. 

Prjeputialis. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfaces of the genitalia. 

Pruriginosus. Accompanied by itching. 

Pebis. Located upon the skin or hairs of the pubes. 

Punctatus. Occurring in dots or points. 

PvHAGADIFormis Fissured, or tending to produce fissures. 

Eosaceus. Having a rosy or pinkish hue. 

Ruber. Red, usually dark red in color. 

Scetiformis. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis. Occurring in advanced years. 

Serpiginoses. Literally, creeping — advancing in irregular gyrations. 

Siccus. Dry, unaccompanied by moisture 

Sclitarius. Having an isolated lesion, or with isolated lesions. 

Symmetricalis. Similarly distributed on the two lateral halves of the body. 

Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

Universalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Variegates. Exhibiting several distinct colors. 



64: GENERAL ETIOLOGY. 

Vasculosus. Accompanied by vascular development. 
Vernalis. Occurring chiefly in the spring of the year. 
Versicolor. Exhibiting several shades of the same color. 
Vulgaris. Of the usual or commonly observed type 



III. 

GENERAL ETIOLOGY. 

The study of the causes of diseases of the skin gives us a glimpse 
of the etiology of diseases in general. Id the lowest representatives 
of life the greatest dangers to existence originate in exposure to 
assault from other and stronger representatives in search of their 
prey, in other terms an external danger. In man, the highest repre- 
sentative of the animal scale, the perils of existence are complicated 
by his social necessities and his artificial methods. He can never, 
however, at any period of his existence, divest himself from the 
necessity of exposure to external peril. The plan of his organs 
and the play of his normal activities are perfect, even to the recovery 
from all but mortal injury and repair of moderate loss. The struggle 
for existence of the ideal man is intended to be with that which is 
without ; his body meanwhile furnishing him with a comfortable 
teneuient and a fair fortress. In the purview of nature there should 
be no internal revolt. When such occurs, it is usually the result of 
his ignorance, his folly, or his vice. 

Viewed in this light, the causes of the diseases of his skin will be 
seen to differ but little from those which induce disease in his other 
organs. Exposed to cold, he suffers from a pneumonia ; to injury, 
a fracture or a dislocation ; to the contact of poisons, he vomits or 
purges ; to contagion from his fellow-man, he has the cholera or 
plague; all these are capable of producing diseases of his skin. But 
meantime his organs have a tender care for themselves and each 
other, compared with which the solicitude of a mother for her child 
becomes insignificant. The stomach refuses to digest itself; the 
lung, unwounded, admits no air to the pleura ; the bladder, so long 
as it is unruptured by violence, permits no drop of urine to pass into 
the peritoneal sac. In the same proportion, and uuder the same 
general law, do the viscera refuse to generate a poison which will in- 
jure the integument ; and the fluids of the body, a vicious " humor" 
which will damage the bones. 

Reasoning thus from analogy alone, it will be seen that the preva- 
lent docrines respecting blood-poisons of internal origin must be 
greatly restricted. Eczema alone, in its manifold forms, furnishes 






GENERAL ETIOLOGY. 65 

more than one-half of all the diseases of the skin ; and yet every 
one of these several forms can be produced at will and artificially 
upon the integument of man. 

Again, it is not to be forgotten that the body is really invested 
with a continuous skin which not only is extended over its outer 
surface, but is also reflected so as to line all passages by which it is 
traversed within. This inner investment, called the mucous mem- 
brane, is as truly a part of the skin as the epidermis and corium of 
the face or hand. This is clear : first, as shown from the facts of 
evolution, because representative animals of the lower scale are found 
capable of complete inversion, by which the outer skin becomes the 
inner, or digestive, and the inner, in turn, the outer or protective 
organ ; second, as shown by histology, the anatomical characters of 
the skin and mucous membrane being similar ; third, as shown by 
pathology, the extroverted mucous membrane rapidly undergoing the 
transformation which causes it to resemble the skin ; while the in- 
verted skin, as when the thighs are by disease kept in continuous 
contact and moistened, assumes the characteristic features of mucous 
membranes. In the study of cutaneous etiology, it is manifestly 
proper to regard as of external origin all causes which operate from 
without upon either the outer or the inner skin of the body. 

This much premised, it can be said that the large proportion of all 
diseases of the integument originate either from the action of solar 
heat and light ; temperature changes at the surface of the body ; 
contact with various fluid and solid substances with the production 
of either frictional, traumatic, or toxic effects ; or the develop- 
ment upon and within the skin, of parasites. It remains merely 
to consider these causes somewhat in detail, remembering that at 
times several influences co-operate in the production of a given 
effect. 

The action of solar light upon the skin is usually coincident with 
the operation of another mode of motion called heat. To the former 
are to be attributed the production of freckles, " tan," and other 
pigmentations of the surface; to the latter, the erythema, eczema, 
and various grades of dermatitis which may follow exposure to the 
direct rays of the sun. Other temperature effects, including those 
produced by extremes of both heat and cold, are to be classed in the 
same category. According to Hebra, exposure of the skin to a 
temperature over 100° Fahrenheit, produces merely a transient ery- 
thema, which under a further elevation of 65° F. will not subside 
for several days. At a temperature of 212° F., all grades of acute 
dermatitis are awakened with the production of bulla?, up to the 
point where complete destruction of the integument occurs 

The influence of the seasons is of the same general character. 
Some cutaneous diseases are worse in summer ; others in winter. 
Prickly heat (lichen tropicus) is peculiar to certain warm seasons ; 
frost-bite and its subsequent hyperemia, exudation, or gangrene, 
occur in winter ; pruritus is common in cold weather ; erythema mul- 
tiforme is most frequent in the autumn and the spring. 

5 



bb GENERAL ETIOLOGY. 

The questions originating when considering the influence of 
climate are so complex that they are differentiated with difficulty. 
They involve the study of soil, potable water, diet, atmospheric 
humidity and temperature, and the sociological conditions of a given 
locality. Pellagra is said to originate in certain countries from the 
diet of the people. The severe forms of ringworm observed in India 
result probably from exuberance of vegetation in the parasite under 
the influence of heat and moisture. The aggravated species of 
scabies seen in Norway is doubtless the product of filth and cold, 
with the itch-mite as an exciting cause. It must, however, be ad- 
mitted that the more extensive the study of diseases claimed to be 
peculiar to given degrees of latitude and longitude, the less they are 
found to depart from the types recognized in other countries. 

Frictional effects are perceptible in the action upon the skin, of 
the clothing. Coarse flannel is known to excite pruritus, especially 
when aided by profuse sweat and the muscular movements of the 
laborer. Trusses, corsets, napkins, "pads," supporters, crutches, 
orthopaedic apparatus, hat-bands, stockings, garters, and a long list 
of similar articles, especially when soiled with physiological or patho- 
logical secretions, are responsible for many disorders. Considering the 
occupations of men, bakers, masons, confectioners, blacksmiths, tailors, 
and an equally long list of laborers and tradesmen suffer from the 
results of friction, to which is often added the influence of trauma- 
tism or the action of chemical irritants. 

Traumatism plays a most important part in cutaneous etiology. 
It includes the action in scratching, of the nails, the knees, heels y 
elbows, etc., well illustrated in the case of infants whose hands are 
confined ; as well as the influence of several articles used for the same 
purpose — pieces of cloth of various kinds, etc. In this way excoria- 
tions, and even infiltrations of the skin, are induced. Under the 
head of traumatisms should be considered also injuries of the surface 
produced by animals, occasionally with the added effect of a toxicant. 
Here are included the wounds produced by lice, fleas, bugs, and 
acari ; the bites of serpents, horses, dogs, and cats ; and the accidents 
producing traumatism of every kind, not omitting the intentional 
wounds inflicted by the surgeon and their results. 

Toxicants operate upon the surface with and without the produc- 
tion of traumatism. Thus the worker in dyes and the wearer of 
the dyed garment manufactured may suffer alike ; while vaccination, 
when it produces a generalized exanthem, operates first in the wound 
made by the lancet of the vaccinator. Medicaments used upon the 
outer skin, such as mercury, croton oil, iodine, antimony, and nitrate 
of silver, are capable of engendering disease ; and those which, being 
swallowed, operate as irritants to the inner skin or mucous mem- 
brane, may have a similar effect. Others being swallowed and sub- 
sequently absorbed from the gastro-intestinal tract, produce a toxic 
effect upon the skin in the effort to eliminate them. Thus the bro- 
mide and iodide of potassium, quinine, arsenic, copaiba, and many 
other articles of the materia mediea, occasion erythematous, vesicular, 






GENERAL ETIOLOGY. 67 

pustular, and bullous rashes of variable persistence and different 
exterDal characteristics. 

To the class of toxicants must be added the articles of food and 
drink, which under ordinary circumstances, and perhaps to the 
majority of individuals, serve to nourish the body, but yet operate 
as poisons to the few. Thus alcoholic drinks, shell-fish, preserved 
meats, certain fruits, cheese, pickles, and many other dietary articles, 
are known to originate or aggravate pruritus, urticaria, eczema, and 
acne. Cracked wheat, Graham bread, oatmeal, and buckwheat have 
been found, in certain susceptible individuals, to induce pruritus, 
urticaria, and occasionally decided roughness of the skin. Any un- 
digested or indigestible article of food may excite similar effects at 
one time and not at another, in the same individual, the resulting 
difference being due to the varying conditions of the alimentary canal. 

An important list of toxicants is furnished by the micro-organisms 
destitute of chlorophyll, whose pathogenic effects depend either upon 
their presence in the blood or tissues or upon the special toxin gene- 
rated after their invasion of the body. Among these may be named 
the staphylococci found in pus ; the streptococcus of erysipelas ; and 
the bacilli of tuberculosis, lepra, and syphilis. All of these are ex- 
ternal sources of disease. Xone is known to be generated de novo 
in the human body. Some require traumatism for their introduction 
into the system ; some do not ; and some are capable of introduction 
both with and without traumatism. 

Some cutaneous diseases are produced by the growth of the vege- 
table parasites upon and within the skin and hairs, and in the folli- 
cles. To this class belong ringworm of the scalp, beard, and skin ; 
tinea versicolor ; and favus. 

Of the causes of diseases named, it may be said that no one of 
them is necessarily productive of such effects. The majority of men 
and women expose themselves daily to the action of light and heat, 
are subjected to friction, suffer from wounds of the integument, and 
come in contact with toxic agents, without exhibiting a disease of the 
skin. Often there is a marked degree of sensitiveness of the integu- 
ment peculiar to the individuals who suffer, which may exhibit itself 
in several members of one family, or exist in one person for but a 
brief period of time. Again, an individual idiosyncrasy may be 
exhibited, in consequence of which an article, harmless to all others,, 
becomes to one person only a source of serious discomfort. 

The various physiological changes of the human body are never 
the causes of diseases of the skin, but at times furnish special oppor- 
tunities for the operation of such causes. Thus in the rapid tissue 
evolution of early life, eczema and lupus are relatively common — 
carcinoma and tinea versicolor rare. At puberty the hairs of the 
beard of the male are liable to the incursions of the trichophyton ;. 
and the nipple and breast of the woman become the seat of eczema 
from epiphora of milk. The old man and the old woman may be- 
come the victims of cancer, aggravated forms of pruritus, and horny 



68 GENERAL ETIOLOGY. 

growths. Dentition, menstruation, pregnancy, and the menopause 
disturb the physiological equilibrium, and at times render the access 
of other disturbing forces exceptionally facile. The sexual appetite 
leads to excesses which bear fruit in attacks of herpes, pruritus, and 
syphilis. And the unceasing excretion from the skin surface, with 
constant deposit there of effete material, may, when there is prolonged 
disregard of the laws of cleanliness, induce a liability to disease of 
the skin, which is especially marked in the case of infants and children. 

The power to transmit skin disease by heredity is of less impor- 
tance than is generally supposed. It is most conspicuous in the in- 
stances of hereditary syphilis ; but even here the transmission of the 
disease is not without singular exceptions, and is limited to certain 
periods of the disease in the progenitors. The transmitted disease is 
also most common in the foetus, which is in direct communication 
with the mother, and rapidly diminishes in frequency with every 
month of separate existence, till late and very late instances of hered- 
itary syphilis have come to be received with suspicion. Many of the 
examples cited of hereditary transmission of cutaneous diseases are, 
without doubt, cases of coincidence, which, considering the number 
of patients affected annually with eczema and psoriasis for example, 
should not be regarded as of very rare occurrence. 

The list of causes recognized as directly productive of diseases of 
the skin are, without question, under special circumstances, capable 
of operating as indirect etiological factors. Temperature changes, 
contacts with the external world in all harmful degrees, and toxicants 
are prime agents in the production of diseases of internal organs ; 
and these, in turn, may induce changes in the skin, of the nature of 
disease. The uterus, the stomach, the liver, the kidney, the heart, 
the nervous centres, and the intestinal tract may become disordered, 
and the result be declared not only in disturbance of the function 
of these organs, but in an attack of urticaria, pruritus, jaundice, or 
erythema. 

Without attempting to decide whether the preponderance of evi- 
dence is in favor of internal or external causes as productive of the 
greater number of cutaneous maladies, it is certain that disorders of 
the digestive tract sustain to many of them a most important relation. 
Thus the several conditions included under the somewhat indefinite 
term " dyspepsia, " gout, habitual constipation due to torpor of the 
intestinal tract, a portal circulation impeded by functional disturb- 
ance of the liver, and many other affections of the alimentary canal 
may each be productive of cutaneous accidents or complicate the re- 
sults of the latter. In the same proportion, diseases of the kidneys, 
suprarenal capsules, spleen, and generative organs of both sexes may 
induce or be complicated by diseases of the skin. 

The influence of the nervous system, when considered in this con- 
nection, may be either directly or indirectly exerted. There is 
scarcely any efflorescence upon the surface of the integument, the 
arrangement of whose lesions is not in part determined by the nervous 
fibres whether with or without the intervention of an effect upon the 



GENERAL ETIOLOGY. 69 

bloodvessels. Both vasomotor and trophic nerve-fibres are capable 
of inducing skin changes either after direct lesion or stimulation of 
the nervous centres, or through the medium of the latter after periph- 
eral accidents of the same kind. Passive congestions of the sur- 
face, leading to cedema and violaceous blush of the skin, often result 
from circulatory changes ; and, in fine, any constitutional disease, by 
impairing general nutrition, arresting repair, hastening waste, or in 
other directions impoverishing the protoplasm of the body, is capable 
of inducing disorder of the skin as in other organs. Thus in cancer, 
chlorosis, anaemia, and cholera there are significant alterations in the 
hue of the integument which not merely possess a diagnostic value 
for the clinician, but attest the sympathetic unity of each organ of 
the body with all others. 

There are authors who affirm, with eminent French dermatologists, 
that certain states or diatheses explain the origin of many cutaneous 
maladies. These diatheses, whether termed " arthritic/' " dartrous," 
" lithaemic," or " herpetic," cannot be demonstrated as efficient 
causes for the production of the diseases attributed to them. The 
chief exponents of these opinions are not agreed among themselves 
as to the names of such supposed systemic conditions, nor as to the 
symptoms by which they are betrayed, nor as to the exact method of 
combating their effects. The claim that these states are of a nature 
analogous to a tuberculous or syphilitic diathesis, is to-day well- 
nigh deprived of foundation, since the bacterial origin of tuberculosis 
and syphilis is at least on the road to demonstration. The complexus 
of symptoms characterized by evolution without demonstrable cause, 
by frequency of recurrence, by obstinacy under treatment, and by 
alternation of cutaneous with other maladies, is no proof of a 
diathesis, but rather of the failure of science to appreciate perfectly 
all the several conditions which produce the result. As to the group 
of phenomena well described by Dr. Da Costa 1 as characteristic of 
lithaemia, even with the fullest recognition of such conditions the 
cutaneous symptoms displayed by those who are the subjects of that 
state are neither constant, uniform, nor peculiar. While no wise 
physician would hesitate to treat patients for the relief of such states 
when there was coincidence of skin disease, he would not be, there- 
fore, justified, even after coincident relief of the entire group of 
symptoms of disease, in attributing one part of this group to a con- 
stant association with the others in the case of all patients. 

Without attempting fully to discuss or to settle these questions, it 
is necessary to establish the fact that the eruptive phenomena in any 
skin are produced by a multitude of ever- shifting and varying com- 
binations of causes. Even the syphilodermata are influenced from 
hour to hour by drugs swallowed, by external irritants, and by con- 
ditions of the general health, such as a transitory diarrhoea, or a fit 
of coughing. In the light of our present knowledge, it is the part 
of the physician, on the one hand, to neglect consideration of no 

1 The Nervous Symptoms of Litheemia. American Journal of the Medical Sciences, p. 313, 1881. 



70 GENERAL DIAGNOSIS. 

efficient factor in the origin or evolution of a cutaneous disorder ; 
and, on the other hand, to refuse to assign to a diathetic state only, a 
group of symptoms which may occur in persons where no such sys- 
temic condition can account for the evidences of disease. 



IV. 

GENERAL DIAGNOSIS. 

The establishment of an accurate diagnosis in cutaneous diseases is 
essential to their successful management. This statement is rendered 
necessary in this connection by the prevalence of a belief among the 
uneducated that the disorders of the skin, exhibited for the most part 
in visible symptoms, can be safely treated on general principles, 
without a recognition of the nature of the malady. By many prac- 
titioners the demand for an accurate diagnosis is ignored in conse- 
quence of a too general impression that the desired end is to be 
pursued through great and perplexing obscurity. Yet with patience, 
method, a habit of careful observation (without which no physician 
is successful), and a reasonable degree of skill, both the practitioner 
and student can, in the large proportion of all cases, attain their 
purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of the affected portion of the integument to 
the eye of him who is consulted with a view to its relief. The 
physician is supposed to inspect this surface attentively for a few 
moments, and then to pronouuce definitely upon the nature of the 
disease present, and the therapeutic measures to be adopted. But far 
more than this is requisite, and, indeed, fully as essential here as in 
the investigation of disease involving any other organ of the body. 

It is first necessary to secure a history of the physical and mental 
condition of the patient in the past ; then should follow the special 
history of the disorders of the skin ; lastly, au examination of the 
affected integument. For the purpose of methodically arriving at 
these facts, and of preserving them for future reference, they should 
be systematically recorded. The following are some of the points 
upon which it will generally be found useful to secure information : 

The name, residence, age, sex, occupation, and married or un- 
married state of the patient should be known, as also, whenever 
practicable, the health-history of parents and children. In the case 
of women it is not only necessary to learn the history of the men- 
strual function in the past, but of the highest importance to be 



GENERAL DIAGNOSIS. 71 

informed as to the previous occurrence of abortions and miscarriages, 
and, if such have occurred, the order observed by these with relation 
to the birth of viable infants. The significance and value of several 
of these facts have been described in the chapter on etiology. With 
respect to the history of the products of conception, it should never 
be forgotten that these have a most important bearing upon the 
question of syphilitic infection ; and the absolute exclusion of syphilis 
in any obscure case is a long step in the direction of an accurate 
diagnosis. In the case of male patients, questions will usually elicit 
either admission or denial of the fact of a precedent or present 
venereal disease, and the answers should be regarded as valueless or 
trustworthy according as they are or are not substantiated by cor- 
roborative clinical facts 

Then should follow some record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear ; and, with respect to the latter, the dates of 
occurrence, recurrence, and convalescence be at least approximately 
discovered. The patient should also make known whether he has 
had refreshing sleep; whether he has undergone mental anxieties 
(domestic, financial, etc.) ; whether he has suffered in his digestive, 
respiratory, circulatory, genito-urinary, or nervous system. 

This much ascertained, the patient should be encouraged to narrate 
as succinctly as possible, and as far as may be in his own terms, the 
history of the present cutaneous disorder. He should give the 
subjective sensations it has produced, as also the objective features 
presented to his own vision and touch. In the case of infants this 
information will, of course, have to be obtained from the mother or 
nurse. The treatment to which the disease has been subjected should 
then be detailed. This frequently furnishes a key alike to the diag- 
nosis and therapy of the disorder. In an incredibly large proportion 
of all cases, ignorantly directed and vicious internal or external 
medication has either begotten or aggravated the disease of the skin. 
This much ascertained, the physician is ready to examine the affected 
surface for himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful 
information of which the patient is totally uuconscious. Much of 
this is difficult to describe, as it is the rich fruit of a wide experience 
and careful scrutiny. With a gentle, courteous, and sympathizing 
manner, the diagnostician must combine the art of a detective and 
the skill of a swordsman. Glancing occasionally at the face of his 
patient while making record of the answers given, he will, of course, 
have observed any eruption upon that portion of the body. He will 
have made a mental note of the temperament of the sufferer, or any 
movement made by the latter indicating a tendency to scratch or rub 
any portion of the skin. He will have noticed the posture, clothing, 



72 GENERAL DIAGNOSIS. 

and head apparel ; the existence of hair on the scalp or extensive 
baldness ; the condition of the exposed hands, as indicating manual 
labor or the reverse ; and, in the absence of facial lesions, will have 
observed the special tint of the skin of the face, as indicating 
ansemia, chlorosis, or a general condition of cachexia. The facial 
expression, as indicative of anxiety or placidity, habits of debauch, 
sexual excesses, etc., will not have escaped his attention. All this 
and much more will have possibly enabled the questioner to direct 
his interrogatories into the channel where they would elicit the most 
useful responses. The posture, cries, facial expression, and general 
condition of nutrition of the infant will have been no less carefully 
noted. 

Proceeding to the examination of the affected integument, the 
physician must assure himself of a good light, as colors are best 
distinguished by daylight, and artificial illumination should be re- 
served for exploration of the cavities of the body. The air of the 
apartment should be sufficiently warm to permit of exposure of the 
person without discomfort. Adult males and children of both sexes 
should have the clothing completely removed, so that all portions of 
the skin may be inspected. One portion of the body may, however, 
be examined, and then recovered, if desired, while the examiner 
proceeds to direct his attention to another. In the case of women 
the investigation should be conducted with all the tact and delicacy 
to which the sex is entitled. 

The examination, whenever practicable, should extend over the 
entire surface of the integument. The importance of this point can 
scarcely be exaggerated. It must be remembered that the physician 
should be very much wiser than his patient, and the assurances of 
the latter are always to be accepted with reserve. Thus, one who 
exposes his leg merely, stating that this is the only part of his body 
affected, may have concealed beneath his clothing extensive vari- 
cosities of the veins of the thigh, a typical syphilitic exanthem over 
the belly, a significant scar on his elbow, an extensive patch of tinea 
versicolor on the surface of the chest, or a blennorrhagic discharge 
from the urethra, the medication of which has induced the rash for 
which he seeks relief. These are not the rare, but the common cases 
of a daily experience. 

Observation should be had at this time, of the general and special 
features of the eruptiou. As to the former, the following consider- 
ations should be borne in mind : 

A symmetrical eruption, one equally distributed over the two 
lateral halves of the body, is rarely the result of an etiological factor 
operating upon the outer skin. It more often points to an efficient 
cause of so-called internal origin, one influencing the inner skin or 
the internal organs. An eruption affecting the covered integument, 
never creeping out upon the exposed surfaces, suggests the operation 
of the clothing ; as the latter may chance to prove the nidus or pro- 
tector of a parasite, the fabric which has been colored by a noxious 
dye, the recipient of a chemically altered secretion, which has proved 



GENERAL DIAGNOSIS. 73 

irritating to the surface, the instrument of friction, or the source of 
increased temperature at the surface by its non- conductivity of heat 
and unseasonable thickness. An eruption, accompanied by excoria- 
tions and scratch-lines, is that usually most severe in the parts most 
accessible to the hands, and least developed where the latter have the 
least play, as over some parts of the back. An eruption limited to 
the hands is likely to be one induced by an agent to which the hands 
alone have been exposed, as those' originating in the trades and 
domestic occupations ; while in the latter, an eruption more distinct 
on the right hand, and especially about the right thumb and index 
finger, tells its own story when the hand-worker is not ambidextrous 
or left-handed. Artificially and intentionally produced eruptions, as 
in malingering, hysteria, mental depravity and insanity, usually 
occur also in parts to which the right hand finds easy access. 

Eruptions occurring on the face, hands, and genitalia of men, or 
face, hands, and mammae of women, point to external contact or 
contagion (poison-ivy, scabies, croton-oil, etc.) ; since, next to the 
face, the hands are more commonly brought in contact with the 
parts named in the sexes respectively, as the wearing apparel of each 
suggests. 

An eruption, limited to the forehead, suggests an inspection of the 
hat-band, the veil, or the overlying false hair ; to the ears of women, 
a glimpse at possibly cheap ear-rings ; to the centre of the root of 
the neck, before or behind, a scrutiny of the collar-buttons and 
collars ; to the anus of the baby, an inquiry as to the changing of 
its napkins ; to the wrists of the adult, a question as to the cuffs 
worn ; to the feet, information respecting gaiters, varicose veins, 
recently cut corns, and ill-fitting shoes. Eruptions springing from 
each of these causes have been long and vainly treated as " diseases 
of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetrically 
operating causes — that is, the accidents of environment, or else influ- 
ences exerted within the body unequally on its two lateral halves. 
Thus an orthopaedic apparatus, worn to correct talipes, excites an 
eczema of the leg only of the affected side ; and zoster of the trunk 
is evident on that side supplied by the intercostal nerve which has 
been inflamed. The greater stress may be laid on this peculiarity, 
as the law of symmetry, in eruptions not occasioned by causes 
operating on the outer skin, is faithfully observed in nature. The 
earlier syphilides, the quinine exanthem, rubeola, and even lupus 
erythematosus, are remarkable illustrations of this fact. 

Proceeding next to the special visible characteristics of the erup- 
tion, the physician will not fail to note an acuteness or chronicity of 
lesions ; their color, size, distribution, tendency to become aggregated 
in patches, or the reverse ; and the evidence presented as to change 
in type, the sequence or coexistence of several lesions at the same 
time — that is, the multiformity (polymorphism) or uniformity of the 
eruption. He will observe whether the limit of the affected skin is 
well defined against that which is normal, or scarcely to be outlined 



74 GENERAL DIAGNOSIS. 

with a pen or pencil. He will rupture a bleb, pustule, or vesicle, 
should such be found, to discover the nature of its contents. He 
will remove one or several crusts in sight, to expose the surface on 
w r hich they rest. He will remove a few scales with the dermal 
curette for a similar reason. He will as carefully inspect the skin 
where the disease has existed, as that where it does exist. He will 
pinch up between his thumb and finger a portion of each, in order 
to determine its infiltrated condition ; its atrophy ; or its attachment 
to the tissues beneath. He will pass his hands over the surface to 
recognize the firmness or softness of the lesions, their dryness or 
moisture, and the existence of sebaceous or perspiratory secretion. 
He will look at the mouths of the follicles, where such secretion is 
retained or abundantly exuded. He will discover any lice, or ova 
on the hair ; any ascarides at play about the anus ; any unnatural 
formation of the nail, or deformity of its matrix. He will examine 
for inguinal, post-cervical, axillary, and epitrochlear adenopathy, and 
will thus be often greatly aided in his task. This done, he will 
question in turn for himself, and by the methods recognized in 
medical science, the organs of the body other than the skin. He 
will inspect the tongue carefully, and then, if he is through with the 
mouth, he will be guilty of great error. The gums rarely deceive 
the questioning eye ; the inside of the lips, fauces, and tonsils are 
all to be searched. A mucous patch here will often echo the story 
of a palmar or a plantar syphiloderm. The laryngoscope may be 
called for in syphilis, cancer, lupus, and leprosy. The degree of 
distention of the belly and the region of hepatic dulness should not 
be overlooked. The genitalia of men, and of children and infants, 
can usually be explored. For women unaffected with syphilis or 
disease limited to these parts, an exception in this particular should 
usually be made. 

With the necessary reserve of all very obscure cases, it may be 
said that the physician who has conscientiously conducted an exami- 
nation after the manner described above, is in possession of the 
diagnosis for which he seeks. If the facts thus acquired have been 
properly recorded, and yet do not spell out such a diagnosis to his 
eyes, they are probably legible to others with a wider experience or 
riper judgment, to whom such a record is shown. It is not claimed 
that this exhaustive method of examination is requisite in every case, 
as, for example, in order to recognize an acne or to differentiate 
erysipelas from erythema. But it is certain that few obscure cases of 
skin disease will remain such under severe scrutiny, and the estab- 
lishment of a thorough and exhaustive method of examination is 
important in the earliest experience with disease. Let the student 
or practitioner conduct such an examination in the first few cases of 
eruption upon the surface of the body for which his advice is sought, 
and he will establish a habit of observation in comparison with 
which his pecuniary or professional success in the management of the 
same cases will be indeed of trivial worth. 

Upon one special point should the inexperienced physician be 



GENERAL PROGNOSIS. 75 

guarded. It relates to the acceptance of a diagnosis which, is not 
based upon such an examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the verdict of even skilled 
practitioners may be founded upon an error. The careful diagnos- 
tician should begin his task in a spirit of skepticism, and pronounce 
definitely only upon ascertained facts. The man who says he has an 
u eczema " may be louse-bitten; the woman who has been u over- 
heated " may prove syphilitic. The patient recognized as suffering 
from ringworm of the beard may not have been infected under the 
hands of the barber. Finally, the eruptions upou patients unmis- 
takably syphilitic are often of other than syphilitic origin. They 
are men, women, and children exposed daily to the accidents from 
which the non-infected suffer. They exhibit acne, physiological alo- 
pecia, and dermatitis medicamentosa equally with those who have not 
sinned sexually. 

The microscope is an instrument whose aid in establishing a diag- 
nosis of cutaneous diseases can rarely be dispensed with. The con- 
tributions it has made to the knowledge had on the subject of path- 
ology are of inestimable value; and as a means of diagnosis it can 
be used with advantage both at the time of the first examination of 
a patient, and afterward for the more leisurely examination of hairs, 
scales, crusts, or portions of tissue. Those unable to secure the 
costlier and elaborate instruments sold by the makers, should take 
pains to provide themselves with a fairly good student's stand and a 
fifth and half inch objective, for use in the diagnosis of skin diseases. 

The diagnosis of special diseases of the skin is described in the 
chapter devoted to each. 



v. 

GENERAL PROGNOSIS. 

The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin diseases. 
Many of the latter are trivial ; some are grave ; a few, inevitably 
fatal in their termination. Thus general exfoliative dermatitis, 
leprosy, sarcoma, carcinoma, at times lichen ruber, aud variola in 
the unprotected, are of grave portent ; while the ordinary congestions 
and exudations, the great majority of all cases of acquired syphilis 
in adults, and the entirely curable diseases induced by parasites do 
not excite alarm in the breast of the average patient with respect to 
his longevity. 



76 GENERAL PROGNOSIS. 

The questions, however, as to his future, which are urgently pressed 
by the victim of cutaneous disease, are both numerous and important. 
He is anxious as to the time during which he must suffer ; as to the 
possibility of conveying his disease to his progeny or other members 
of his family ; as to the disfigurement of his person which might 
result ; as to the scars which he may have to carry for the remainder 
of his life ; as to the possible recurrences of his malady in the future. 
The responses to these questions will be largely influenced by the 
prognosis of the physician. 

Some diseases of the skin are acute, rapidly pursue their course, 
and are then prompt to disappear. Others are chronic, rebellious to 
treatment of the most energetic and skilful character. Others, 
again, though not shortening life, are never relieved while life is 
continued. Some disappear, only to reappear at more or less regular 
intervals. There are cutaneous diseases which affect one individual 
but once in his lifetime ; others which reappear at the instant the 
patient is again exposed to their exciting cause. There are cutaneous 
diseases so distorting and destructive in their effects, that their vic- 
tims have committed suicide under the influence of the morbid emo- 
tions which they have as a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its exciting cause ; and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by au acne ; and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the other. Thus there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated with 
albuminuria ; and the eczema of an infant starving for want of 
breast-milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prog- 
nosis of the disease of the latter, will largely depend the professional 
success of the physician. Scrupulous honesty should be here welded 
with all the skill that science can command. That a disease does not 
endanger life is not an argument in favor of its amenability to treat- 
ment. The practitioner should never suffer himself to be pushed by 
his patient to the position that an obstinate disease is readily manage- 
able. It is the height of folly to estimate lightly that zoster of the 
forehead, the scars of which the patient may exhibit to all who after- 
ward look upon his face both in life and death. He who engages to 
relieve an alopecia areata in the mouth, may have a year in which to 
repent his precipitancy. There is no way in which the conscientious 
physiciau can so readily secure the confidence of his patient, and 
with it that willingness to submit to appropriate treatment, which is 
begotten of such confidence, as by demonstrating his ability to forecast 
the future of a disease; in other words, to describe accurately its 
prognosis. 






GENERAL THERAPEUTICS. 77 



VI. 
GENERAL THERAPEUTICS. 

A consideration of the subject of the methods of treating skin 
•diseases in general suggests at once the intimate relation which sub- 
sists between the integument and other organs of the body. The 
etiology of one largely explains the causes of the diseases in all. 
The pathological processes in each are subordinated to the same 
general laws. The principles of treatment are very similar in all 
the disorders of the body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; second, where the latter is impossible, such a 
management of the morbid processes as will mitigate its severity and 
render the victim of the disease more comfortable. A higher and 
more scientific achievement than either is the prophylaxis by which 
man is enabled to escape the disease altogether. He can by his wis- 
dom largely diminish the danger to which his integument is exposed. 
He can, to a certain extent, shelter himself from extremes of tem- 
perature, traumatism, toxic agents, and the contagious diseases. He 
can, by observing the simple rules of hygiene, fortify his skin against 
the lesser evils which may befall it. If it be true that " the people 
perish for the want of knowledge," it is certain that once in posses- 
sion of it, they can greatly enhance their comfort and prolong exist- 
ence. Here, however, the subject under consideration involves 
disease which is actually present and in progress. 

Like all other diseases of the body, those of the skin may be 
divided into three classes with relatively fixed limits. 

The first embraces all the diseases which have a natural tendency 
to pursue their course to a favorable termination. It embraces all 
those affections which, either mild or severe, require absolutely no 
treatment of an active character. It is the duty of the skilful phy- 
sician to watch the evolution of these maladies, and to discharge a 
most important part by refraining from all therapeutic measures 
which in such cases might prove hurtful. By his judicious counsel, 
also, he hinders patients and their friends from pursuing a course 
which might prove prejudicial to the disease. 

The second class embraces all those affections of the skin which 
are either inevitably fatal or hopelessly remediless while life is pro- 
longed. Fortunately, this includes but a small proportion of the 
large list. Here the duty of the physician is plain. He should 
assuage pain, attempt to relieve deformity, administer to the comfort 
of the afflicted in other ways, and, by his patient courage, inspire 
confidence and hope. It must not be forgotten that the skill of man 



78 GENERAL THERAPEUTICS. 

has not yet reached the acme of human need. In the presence of 
many diseases of the body, he stands absolutely helpless ; and the 
speediest way to success in such cases is to begin by an honest admis- 
sion of the plain fact. 

The third class of affections naturally embraces all not included 
in the other two. Here disease may be prolonged or shortened in 
its course, rendered acute or chronic, made more or less endurable, 
permitted to become inveterate, or be absolutely relieved, by prompt 
and energetic measures, according as it is, or is not, judiciously and 
skilfully managed. Here are gained the most brilliant successes of 
the dermatologist ; here also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment 
a question naturally arises as to whether this treatment shall be in- 
ternal, that is, by medicaments ingested ; or external, that is, by local 
therapeusis ; or by combination of the two methods at the same time. 



With regard to the first question (concerning the Internal treat- 
ment of skin affections), which is one of pressing importance, it can 
be safely said that there are no remedies to be given by the mouth 
which can be described as certainly and specifically curative of the 
diseases of the skin. The number of medicinal agents employed 
with this end in view is incredibly large, by far the greater part 
being obtained from the vegetable kingdom. With few exceptions, 
for the most part enumerated below, the most esteemed of these exert 
only an indirect therapeutical effect upon the integument. The 
larger number of medicaments thus used are, it must be admitted, 
without value of any kind, but will probably continue to be vaunted 
as possessing specific virtue so long as credulity on the one hand, and 
avarice on the other, move the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as 
valuable, when ingested, for the relief of cutaneous disorders. It 
is known to exert its effects almost exclusively upon the epithelia of 
the skin, and upon these, so far as therapeutic effects are concerned, 
only when they are affected by subacute and chronic exudation. It 
is known to exert an unfavorable influence upon the epidermis when 
the latter is in a condition of active inflammation. Operating in 
this limited class of cases favorably, it also operates slowly, requiring 
months for the production of its curative effects. Its administration 
is at all times attended with the hazard of producing toxic effects, 
which, however, when the result of the exhibition of the drug in 
medicinal doses, are usually limited to a mild exanthem upon the 
skin, moderate coryza, and some redness from congestion of the 
vessels in the eyes and eyelids. 

It is used chiefly in psoriasis, acne, squamous eczema, pemphigus, 
and lichen ruber; its dosage in cases of children being relatively 
large. It should be invariably administered only after eating, and a 
minimum dose be first employed in order to test the susceptibility of 



GENERAL THERAPEUTICS. 79 

the patient to its action. It should be remembered that the toxic 
effect of this, as also of several of the other drags mentioned below, 
is often speedily noticed after the first exhibition of a relatively small 
dose. Toleration once established, the dosage may be cautiously 
increased. 

The forms in which it is usually administered are the preparations 
of arsenious acid, such as the liquor potassii arsenitis (Fowler's solu- 
tion) ; the liquor arsenici et hydrargyri iodidi (Donovan's solution) ; 
the liquor arsenici chloridi ; and the Asiatic pill. Duhring's modi- 
fication of this pill is obtained by makiug two grains (0.13) of 
arsenious acid, and thirty-two grains (2.2) each of black pepper and 
liquorice powder, into thirty-two pills by the aid of a sufficient 
quantity of mucilage. Arsenic is also at times advantageously com- 
bined with other indicated medicinal substances, such as iron and the 
iodide of potassium. 

In the first edition of this treatise it was stated that an unpreju- 
diced view of its action, even in cases properly selected for its in- 
ternal administration, would justify the conclusion that arsenic is in 
diseases of the skin a remedy of uncertain effect, and, in that pro- 
portion, disappointing. Subsequent investigation, made particularly 
by American observers, has more than established this position. Dr. 
G. H. Fox, of New York, 1 after collation of the experience of a 
number of experts in this country concluded that the common prac- 
tice of giving arsenic in many cutaneous diseases was both harmful 
and irrational, not merely because of its effect in inducing cutaneous 
congestion and pruritus, but because of the reliance placed upon it 
to the exclusion of other and better methods of treatment ; and that 
the beneficial effects supposed to follow its administration were often 
due to other causes. He also called attention to the striking fact 
that no series of carefully recorded cases had ever been published in 
which notable therapeutical results had been shown to result solely 
from its administration. 

These conclusions elicited a number of statements from well- 
known physicians having experience in the management of cutaneous 
diseases, who, for the most part, assented to Dr. Fox's conclusions. 
Even in pemphigus, psoriasis, chronic eczema, and lichen ruber, 
where the remedy has been thought to possess special efficacy, it has 
in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of 
the earliest, should be one of the last remedies selected in the man- 
agement of cutaueous diseases by the general practitioner ; second, 
that, when thus selected, its value will probably prove greatest if the 
eruptive lesion be superficially seated, generalized, diffused, or in evi- 
dent association with neurotic symptoms ; third, that in any case its 
failure should not be regarded as definite, if only Fowler's solution 
has been administered. 

1 Journal of Cutaneous and Venereal Diseases. June, 1886, p. 179. 



80 GENERAL THERAPEUTICS. 

The value of Mercury in the syphilodermata is incontestable, 
and its injudicious employment in many cases springs from that 
precise fact. The vulgar prejudice that many disorders of the skin, 
really not syphilitic, are obscure manifestations of lues in a preceding 
generation, and amenable to mercurial treatment, is a striking illus- 
tration of the necessity of accurate diagnosis in cutaneous diseases. 
Few non- syphilitic affections are benefited by continuous courses of 
mercury, though the value of the metal as an alterative in this 
small proportion of cases must be admitted. The corrosive sub- 
limate is often superseded, in consequence of its irritative effects, by 
the compounds of the metal with iodine. The gray powder is useful 
chiefly in case of infants and children, though its not infrequent 
development of the corrosive chloride has largely limited its favor 
with Americans. Calomel and the mercurial pill should be employed 
only for transient effect, as, when administered for long periods, they 
are much more apt to produce ptyalism than the other preparations 
mentioned. 

Iodine and its compounds are also chiefly used in syphilitic dis- 
orders of the skin, but they possess a wider range of value than the 
mercurials in the treatment of other cutaneous affections. Here, too, 
the abuse of the drug furnishes a long list of cutaneous disorders 
either originated or aggravated by its employment. As in the use of 
arsenic, toleration should be established before large doses are ex- 
hibited. The compounds chiefly used are the iodides of potassium, 
sodium, lithium, and ammonium ; and iodoform. It has been admin- 
istered for the relief of the scrofulodermata, lupus, keloid, and 
syphilitic affections of the skin. As to the latter it may be added 
that in the earlier symptoms of lues it is often a source of positive 
injury. 

Cod-liver Oil is a remedy of special value in diseases of the 
skin, and was for that reason held in high favor by the distinguished 
Hebra, though its action is almost exclusively that of a nutrient of 
the general system. It is employed chiefly for its roborant effects, 
and these are similar to those of the digestible aliments. Its special 
value in the treatment of infants and children affected with cutaneous 
diseases cannot be questioned. It is, however, of great use also in 
maturer years, and is advantageously exhibited in eczema, lupus, 
scrofula, syphilis, scleroderma, and in all the disorders of the integu- 
ment accompanied by wasting. 

Quinine, administered both as a tonic and antiperiodic, is largely 
employed in cutaneous medicine for its generally recognized systemic 
effects. It produces, in certain susceptible individuals, a peculiar 
smoothness and softness of the skin, which usually disappear when 
the drug is suspended. Like arsenic and iodine, it is occasionally 
the cause of a generalized exanthem, and is capable of producing 
other toxic effects, such as failure of the heart's action, dizziness, and 






GENERAL THERAPEUTICS. 81 

tinnitus aurium, symptoms recognized under the designation of cin- 
chonism. It will, of course, exhibit its happiest effects in malarial 
affections with coincidence of cutaneous symptoms in the forms of 
disease of the skin associated with a neurosis. 

Ergot, whether by exerting an effect upon the muscle-bundles or 
vessels of the derma, or upon the uterus, or yet by its influence upon 
the general economy, is thought to possess some value in the treat- 
ment of several cutaneous diseases occurring in both sexes. Such 
are acne, purpura, and a few other disorders. 

Calx Sulphurata may be regarded as the most efficient of the 
sulphur compounds for internal use in cutaneous diseases. Its recog- 
nized value in furunculosis has led to its employment also in eczema, 
acne, and impetigo. It is given in doses of from one-tenth (0.004) 
to one-fourth (0.016) of a grain, three or four times daily. Chrysa- 
robin has been administered internally by Stocquart 1 and others in 
doses of one-sixth (0.01) of a grain, for a number of cutaneous dis- 
orders. Ichthyol, mentioned later as of some value when exter- 
nally employed, has also been given by the mouth. Jaborandi and 
Pilocarpine, probably as a result of the free diaphoresis which 
they excite, have unquestionably exerted immediate therapeutic 
effects in a number of cutaneous disorders. 

Sulphur, highly esteemed as a popular remedy in cutaneous 
affections, exerts but little influence upon the latter when it is 
ingested. Its cathartic effect is the chief reason for its administra- 
tion. It is recommended by Crocker in some of the disorders of the 
sweat- function. 

Antimony iu small doses is of unquestioned value in many dis- 
eases of the skin. It is, when not contra-indicated, employed with 
advantage in cases of psoriasis, pruritus, and some of the obstinate 
forms of eczema. 

Tar, Carbolic Acid, Eesorcin, Turpentine, Copaiba, and 
Phosphorus are remedies which have been employed internally with 
appreciable effect in certain cutaneous maladies, but the action of 
each is uncertain, and at times highly prejudicial. They have been 
used with advantage in cases of lupus, eczema, psoriasis, and pruri- 
tus ; but the disagreeable effect of their internal administration has 
been to a great degree a bar to their general employment. The 
Aperies" of phosphorus, and the elegant elixirs of the same drug 
now in the market, seem to have obviated this difficulty in the 
instance of at least one of these articles. 

Unpromising as is confessedly this brief review of the remedial 
influence which internal medicaments are capable of directly exerting 

1 Ann. de Derm, et de Syph. 1884. 
G 



82 GENERAL THERAPEUTICS. 

upon the skin, it must not be forgotten that, while the treatment of 
the patient and the treatment of the patient's skin are practically 
one, there is some distinction to be drawn between them. No one 
would claim that castor oil, for example, possessed any efficacy in the 
fracture of a femur, yet such a cathartic is frequently ordered by the 
surgeon, with the happiest effect upon the condition of his patient in 
a splint. Such precisely is the inestimable value of a properly con- 
ducted internal medication in cases of cutaneous disease. 

The consideration of this point introduces at once and properly 
to the broad field of general medicine. He is totally unfit to treat 
cutaneous diseases who is not qualified by education and experience 
for the general practice of medicine. The internal treatment of the 
patient suffering from a disease of the skin is that which is in each 
case indicated by his general condition. Thus the aperients, cathar- 
tics, diuretics, and occasionally even the anodynes, are demanded, 
and, when judiciously employed, accomplish beneficial results. Few 
practitioners can afford to dispense with the use of the preparations 
of iron, for example, in cases of anaemia. Even the patient affected 
with a parasitic disease may need one of the bitter tonics, and the 
youth with vegetations upon the glans may require first to be rid of 
his blennorrhagia. 

Among the medicinal substances indicated by the general condition 
of the patient affected with a disease of the skin, yet not directly 
acting upon that organ, none are more useful than the diuretics, 
cathartics, and remedies acting as stimulants to the secretions of the 
chylopoietic viscera. At this day no educated physician believes in 
employing medicines with a view to either the so-called "driving 
out " or " driving in " of a disease of the skin, much less to a use of 
evacuauts with a view to carrying off a supposititious materies morbi. 
The remedies suggested above are undoubtedly, for the most part, 
useful in diminishing the congestion of the cutaneous capillaries, an 
important point not only with respect to the comfort of the patient 
but to the relief of his ailment. 

He who accomplishes the largest success will not, finally, neglect 
consideration of the diet, hygiene, and social surroundings of the 
patient. The chief value of many of the mineral springs and health 
resorts of this country lies in the change of the manner of living 
which they invite and necessitate. Sunshine, pure air, recreation 
after the care and toil of business, change of climate, of foods and 
drinks, and even of cooks, often decide the question of speedy re- 
covery. Unfortunately, both in this country and abroad, many of 
the health resorts are peopled by unscrupulous charlatans, with a 
myopic tendency to attribute all the benefits to be derived from these 
sources to the medicinal virtues of this or that particular spring, 
aided always by treatment according to their own peculiar methods. 
Many patients affected with disease of the skin are thus made worse 
by a temporary residence at noted health resorts, and, therefore, it is 
often the case that a visit to the seashore, the mountains, or any 



GENERAL THERAPEUTICS. 83 

healthful place in the country proves conducive to far greater practi- 
cal results. 

This understood, it is admitted that many of the springs of our 
own country possess a therapeutic value in cutaneous diseases ac- 
tually dependent upon the constituents of their waters. A new study 
of this interesting and important subject is demanded by the annual 
discovery of new sources within the borders of the United States, 
which give a large promise for the future. Many of those ignorantly 
recommended as valuable for the entire list of cutaneous disorders 
are either entitled to no such encomium or may be usefully employed 
only in a limited number of skin affections. Large successes are 
undoubtedly to be credited to the scores of ferruginous, sulphuretted, 
chlorinated, alkaline, arsenical, purgative, and other springs whose 
names appear in the lists given by European writers on this subject. 
Most of these are represented in this country by waters of equal, if 
not greater value, furnished by the numerous spas of Michigan, Vir- 
ginia, New York, Colorado, New Mexico, Utah, and other States 
and Territories of the Union. As these are brought within reach of 
a larger portion of the population of the country by greater railway 
facilities, their medicinal value will be better appreciated, and they 
will be much more systematically employed than at present. They 
offer a most promising future for the internal treatment of diseases 
of the skin in this country. 



In the External treatment of diseases of the skin, the indica- 
tions are, to hasten repair when this is possible ; to alleviate distress, 
if palliatives only are admissible ; to destroy absolutely or excise the 
diseased tissue, when this is justifiable. The following are the prin- 
cipal substances employed as external applications : 

Water, either pure or medicated by holding other substances in 
solution or mechanical suspension, is applied either in baths or 
lotions. Baths, local or general, may be employed for days contin- 
uously, or but for a few moments at a time. They are given with 
water of varying temperature, cold, warm, or hot. Cold baths of 
short duration are generally followed by a sharp reaction, the skin 
becoming congested after the normal temperature of the surface is 
regained. Thus it is that cold sponging of the inflamed skin is 
usually grateful so long as it is continued ; and is succeeded after- 
ward by an aggravation of the symptoms which it was intended to 
relieve. Continued applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation of 
the integument, while those given with tepid water are chiefly 
macerative of the surface. It should be remembered that the appli- 
cation of watery lotions to the broken surface of the skin is liable 
to be followed by endosmosis, unless the specific gravity of the serum 
of the blood and that of the fluid of the bath or lotion are nearly 



84 GENERAL THERAPEUTICS. 

the same. This imbibition of fluids by the broken skin is accom- 
panied by slight swelling of the tissues and productive of disagree- 
able sensations. 

The most perfect of all methods by which water is applied to the 
surface of the body is that which most resembles the water-bath in 
which the tender skin of the foetus is safely immersed for consecutive 
months. Here the bath is continuous ; the temperature, that of the 
viscera of the living animal ; aud the delicate skin of the unborn 
child, anointed with a fatty substance which actually interferes with 
the macerative action of the surrounding fluid so long as vitality is 
preserved at the average standard. The comfort and therapeutic 
value of a bath prepared and administered in approximation to this 
ideal can scarcely be overestimated. Were it not for the difficulties 
with which it is attended, so far as relates to many portions of the 
surface of the body, it would be possible with this single therapeutic 
measure to rob the exudative affections of the skin of a great part of 
their formidable features. 

In acute inflammations of the skin, the application of pure water, 
even when of proper temperature, is often prejudicial to the integu- 
ment ; and soap and water washings may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients as 
to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by the 
addition of a large number of substances, such as marine salt, sodic 
and potassic salts, alum, tannin, the mineral acids, mucilages, gelatin, 
bran, and, especially in the Southern States of this country, the 
orange leaf. 

The alkaline bath, made by adding the bicarbonate or the biborate 
of sodium to water of the proper temperature in the proportion of 
twelve ounces of either salt to thirty gallons, is usually grateful to 
the inflamed skin. Sulphur baths are best prepared by adding an 
ounce of Yleminckx's solution 1 to the same quantity of water. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, carbolic acid, 
hydrocyanic acid, zinc, bismuth, mercury, lead, and the alkaline 
bicarbonates with the sodic biborate. It is rendered stimulating by 
the admixture of alcohol, most of the acids and alkalies in stronger 
solution than in the soothing or sedative lotions ; and by a large 
number of substances which operate upon the surface either mechani- 
cally or chemically. It is also rendered astringent when tannin, lead, 
and similar medicaments are dissolved in it ; and by its union in 
various degrees with soaps and alkalies a solvent effect is produced, 
either upon the cuticle itself or upon pathological or foreign products 
upon its surface. 



1 The formula is : 






J£fc. Calcis, 


gss: 


16) 


Sulphur, sublim. 


Sj; 


32 


Aq. dest. 


Sx; 


320| 


Coque ad Svj [200] deinde filtra. 






Sig. "Vleminckx's Solution." 







GENERAL THERAPEUTICS. 85 

" Over-fatty," or " superfatted " soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight ex- 
cess of unsaponified fat. They are exceedingly mild in their deter- 
sive action upon the skin, though the lather produced in their use is 
not as abundant as with the alkaline soaps. These are usually pro- 
prietary articles. 

Medicated Soaps, containing carbolic acid, glycerine, tar, sul- 
phur, and various oils, are sold in the shops, but contain so small a 
portion of the individual medicament from which each is named that 
they are practically worthless except for purposes of ablution. The 
author has had such prepared under cold pressure, so as to contain 
medicinal substances in therapeutic proportions ; but after experi- 
mentation, has concluded that other forms of administration are 
preferable. 

Fatty and Oily Substances are applied to the skin either 
directly by pouring, or by friction, or by the mediation of com- 
presses, bandages, etc., which are saturated or spread with the mate- 
rial to be applied. The oils may be used for either nutritive, sooth- 
ing, or stimulating effects. To the first and second classes belong 
cod-liver, lard, olive, almond, linseed, neat's-foot, castor, and similar 
oils ; to the third class, the oil of tar, of cade, of white birch, of the 
cashew nut, and of juniper. 

Fatty substances are also applied in the form of ointments or 
pomades. They are compounded with various medicinal substances, 
according to the requirements of each case, such as the salts of mer- 
cury, zinc, copper, lead, and sulphur ; pyrogallol, chrysarobin, car- 
bolic and hyposulphurous acids ; tar, camphor, iodoform, balsam of 
Peru, hydrate of chloral, the extracts of opium, belladonna, etc. 

The products of petroleum refinement, known as Vaseline and 
Cosmoline, though not true fats, are increasingly employed for 
similar purposes, and continue to enjoy high favor in this country 
and abroad. They are particularly useful as bases for ointments for 
application to the hairy portions of the body, such as the scalp, when 
more consistent salves paste the hairs to the surface in an unsightly 
mass. 

Glycerin — even the best — is, when applied in its purity to the 
skin, usually irritating. It is, however, exceedingly useful when 
diluted or made a component part of lotions and ointments. When 
combined with starch it makes, in different proportions, a series of 
combinations known as glyceroles, or glycerolates. These are pasty, 
semi-solid substances which are capable of varied medication, as in 
the glycerole of the subacetate of lead. They are useful chiefly as 
protectives of the surface. Glycerin, when used in a fluid soap, is 
an exceedingly valuable agent when a milder effect is desired than 
that produced by the spirit of soap described above. The Vienna 



86 GENERAL THERAPEUTICS. 

preparation known as Sarg's fluid soap is an admirable substitute of 
this sort when a soft shampoo is required for the scalp. 

The Pastes employed for local application in diseases of the skin 
have been greatly perfected by Lassar aud Unua. 1 

These pastes are valuable especially in the exudative affections, 
where salves are often either not well tolerated or actually prove 
irritating to the skin. The pastes, when applied to such surfaces, 
form a protective and adhesive dressing, which may be medicated as 
desired. 

They are prepared with kaolin [terra alba, or Armenian bole of 
red color, when it is desirable to have the application resemble the 
color of the skin], gum, lead, dextrine, glycerin, and other sub- 
stances. Formulae for each are here appended : 

Kaolin in a pure state, with equal parts of vaseline or glycerin, 
or with almond, olive, or linseed oil, in the proportion of two to one, 
is readily applied iu a thin layer over the skin. When it is desired 
to add the oxide of ziuc, or the plumbic acetate, the kaolin and oil 
or glycerin are first carefully mixed, in order to prevent the forma- 
tion of an insoluble compound — e. g , 3^. Kaolini pur., ol. lini [vel 
glycerini], aa 30 parts ; zinci oxidi, liq. plumb, subacetat., aa 20. M. 

For making lead pastes, litharge is boiled with twice the quantity 
of vinegar till the latter has evaporated and a damp but drying paste 
is left, which may be, on occasion, remoistened witli a small quantity 
of vinegar — e. g., 1^ Lithargyr. subt. pulv. 50; aceti, 80. Coque 
usque ad consistent, pastse : deinde adde ol. lini [v. glycerini, v. ol. 
oliva?], 10. M. 

In the two forms of pastes above described, the adhesive aud 
desiccative qualities are obtained from the main ingredients, but in 
those resultiug from combinations of gum, starch, and dextrine, 
these results are for the most part obtained by the addition of other 
ingredients, such as sulphur, zinc, etc. A good basis, semi-solid, 
rapidly drying, and fixing its ingredients well upon the surface, is 
the following: ^. Amyli oryzse, 8; glycerini, 2; aq. dest. 15. M. 
Coque ad remanent. 15. For convenience, the solid substances are 
mixed at once with the glycerin, starch, and water, and then heated 
together. 3^. Zinci oxid. 50 ; acid, salicylic. 2 ; amyli oryzse, gly- 
cerini, aa 15 ; aq. dest. 75. Coque ad 140. For a sulphur paste : 
Ify. Sulphur, prsecipit. 40; calc. carb. 2; ziuc. oxid. 20; amyl. 
oryzse, 15 ; glycerini, 20 ; aq. dest. 75. Coque ad 120 

Here is a formula giving a combination of starch and lead resemb- 
ling cream: ]^. Amyli oryzae, 10; glycerin. 30; lithargyr. 30; 
acet. 60. Evapora ad 80. By adding 10 parts more of litharge, 
and 20 more of vinegar, and evaporating to 90, a thicker aud cement- 
like paste is formed. 

To make use of dextrine, the officinal pulverized article is selected, 
and a simple paste of this forms a good drying base. An added 

1 Monatsh. f. prakt. Derm., February and March, 1884. 



GENERAL THERAPEUTICS. 87 

half-weight of glycerin is required if powders are also combined 
with the paste — e. g., 1^. Zinc. oxid. 40 ; dextrin., aq. dest, aa 20 ; 
glycerin. 40; sulphur, soblim. [vel sod. sulpho-ichthyol.] 2. Coq. 
A mixture of dextrine and lead is thus prepared : ]^. Lithargyr. 
30 ; acet. 50. Coque ad remanent. 50 ; adde dextrin. , aq., glycerin., 
aa 15. Coque. If too consistent, these pastes are made to spread 
easily by the addition of a few drops of hot water. Such water is not 
required in making the paste if another fluid be one of the constitu- 
ents, as, 1^. Dextrin , glycerin., liq. plumb, subacet., aa 10. M. 
Coq. ft. pasta. 

For the gum pastes, gum arabic is used in the proportion of one 
part of mucilage and glycerin to two of the powder selected, mixed 
without heat — e. g., Iy. Zinc. oxid. 40 ; hydrarg. oxid. rub. 2 ; 
mucilag. acac, glycerin., aa 20. M. 1^. Cret. preeparat, sulphur, 
sublim., aa 2 ; picis liquid. 8 ; amyli, 20 ; mucilag. acac, glycerin., 
aa 15. M. 1^. Acid, salicylic. 20 ; glycerin. 20 ; mucilag. acac. 30 ; 
ol. ricini, 10. M. 

The following details are to be noted respecting the availability 
of these pastes for different ingredients : Lead is best used as an 
acetate, either in a simple paste or with dextrine, the carbonate, 
oleate, and iodide combining well with both. Zinc oxide combines 
well with kaolin, lead, starch, dextrine, and gum. Sulphur combines 
well with the three last named, poorly with kaolin, and not at all 
with lead. Ichthyol suits well with all save the gum pastes. 
Naphthol, calomel, corrosive sublimate, red and white precipitate, 
carbolic acid, chloral hydrate, camphor, and salicylic acid can be 
incorporated with all, the last named in smaller proportion with 
gum paste. Tar is better united with starch, dextrine, and gum, 
than with the others. Iodine and iodoform naturally do not suit 
well with the starch and dextrine pastes. Chrysarobin and pyro- 
gallol are united with kaolin and gum pastes, but acids in general 
destroy the adhesiveness of the gum pastes and should not be added 
to them. Fatty and soapy substances, if commingled in large 
amounts with these pastes, injure their special properties. 

Powders are mechanically dusted over the surface of the skin for 
the purpose of protecting it, and occasionally in order, also, to pro- 
duce an astringent or anti-pruritic effect. In order to be serviceable, 
they should generally be rendered impalpable by sifting them care- 
fully through a fine silk bolting-cloth. They are composed of starch, 
talc, magnesia, lycopodium, bismuth, boric acid, camphor, tannin, 
oxide of zinc, iodoform, salicylic acid, and similar substances. The 
articles sold by grocers as " Oswego Gloss Starch" and " Corn Starch 
Farina" are usually much more finely bolted than the dusting-pow- 
ders extemporaneously prepared by chemists. As absorbent powders, 
the starchy substances are open to the objection of forming little 
pasty rolls or " cakes," when wet with serum or sweat. Lycopo- 
dium, which is seen under the microscope to consist of irregularly 



88 GENERAL THERAPEUTICS. 

globular pollen sporules, never behaves in this way, and is, for that 
reason, deservedly popular. 

Dr. Faithful, of Australia, has suggested the preparation of 
medicated powders by first dissolving them in alcohol, ether, or 
chloroform. The solution is then mixed with starch or French 
chalk. Evaporation of the menstruum is conducted without arti- 
ficial heat, and a fine, medicated starch or chalk powder results. 

Plasters are employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin plasters are less useful in skin diseases, 
because more irritating than the lead plasters. Unna's plaster-mulls 
are described below. The mercurial plasters are useful, especially in 
syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by Unna. His Salve- 
muslins or salve-mulls are strips or bandages of muslin thoroughly 
impregnated and thickly spread with ointments medicated by almost 
every desirable substance, from the oxide of zinc to tar, thymol, 
salicylic acid, and mercury. They are elegantly made, and, when 
imported to this country, surrounded by impermeable tissue, so as to 
be quite fresh aud sweet when used. They are efficacious, and, as a 
rule, well liked by patients. The chief objection to their general 
employment in this country is the expense of importation. They 
are available in skin diseases of the exudative class affecting the ex- 
tremities ; but should be avoided when not recently prepared. 

Unna's " Plaster-mulls " seem to be less useful. They are 
plasters thinly spread on gutta-percha cloth, and manufactured with 
a wide range of medicinal constituents. They serve a good purpose 
in the protection of parts of the skin exposed to friction. 

Poultices are not often ordered in the management of diseases 
of the skin, except for the purpose of softening crusts with a view 
to their removal. These applications are objectionable in all con- 
ditions where a macerative effect of the epidermis is produced ; and 
also where micro-organisms may find a genial culture-field in the 
mass of the poultice. Poultices, in any needful case, may be made 
antiseptic by the addition of the mercuric bichloride. 

Lanolin, or wool-fat, was first introduced as a salve-base by Dr. 
Oscar Liebreich, of Berlin. It is a peculiar substance obtained from 
keratinic tissues, and contains cholesterin fat instead of glycerin, 
with but thirty per cent, of water. It has a bright yellowish color, 
a distinct odor of the sheep, and is neutral ; never, when pure, acid 
in reaction. The Berlin specimens that first came to this market 
required the addition of from ten to twenty per cent, of an ordinary 
fat in order to overcome the consistency of the lanolin. But, in 
1886, Prof. Liebreich called attention to a lanolinum purissimum 



GENERAL THERAPEUTICS. 89 

which he had substituted for the former, aud which, beiug free from 
cholesteriu compounds, required no such fatty addition. 

This substance seems now to have outlived the period both of 
extravagant praise and denunciation. It is readily absorbed from 
the surface of the skin, and, either pure or medicated, may be 
regarded simply as a useful addition to the bases of ointments for 
employment upon the skin. 

The Oleates of zinc, mercury, copper, lead, and other metals 
have been employed with advantage in the topical treatment of 
disorders of the skin. Of these, the oleates of mercury and lead are 
decidedly the most valuable. The latter is represented by Hebra's 
white diachylon ointment. The oleate of mercury is serviceable in 
syphilitic, parasitic, and other disorders. 

Collodion and Traumaticine are employed for the purpose of 
applying a remedy to the skin, and at the same time protecting or 
contracting the surface to which the application is made. Traumati- 
cine is the name given to a solution of gutta-percha in chloroform, 
in the proportion of ten per cent. In this way bismuth, cautharides, 
sulphur, chrysarobin, oxide of zinc, white precipitate, iodine, and 
other substances may be with advantage applied to the surface, and 
the action of each definitely limited to the margins of a single patch 
of disease. 

The several varieties of Tar, crude and distilled, together with its 
derivatives, occupy an important place among efficient topical agents. 
In general, they seem to exert upon the epidermis a local influence, 
which extends more deeply as the remedy is continuously applied. 
At times, both irritative and inflammatory effects are thus induced ; 
and when absorption from the skin occurs, even systemic intoxica- 
tion. Pix liquida, or the oleum picis, is the favorite article of this 
group with most American physicians ■ but the oleum cadini, or oil 
of juniper, and the oleum rusci, or oil of birch, are rather more 
generally employed by experts. The last-named, found in purity 
and abundance and to be had at a low price in our own markets, is 
recommended above the others. In Vienna the distilled oil is 
preferred; but there is good reason to believe that the crude oil is 
decidedly more efficacious. 

The skill of a physician intrusted with the management of a dis- 
ease of the skin might almost be measured by his success in the use 
of tar. He who has not had experience in its employment is 
urgently advised to select one member of the tar family and learn 
thoroughly how to apply that, singly and in combination, either in 
lotion or salve. Properly employed, it will favor involution of 
lesions, lessening hyperemia, infiltration, scaling, and discharge. It 
serves admirably as an antipruritic. As suggested above, it may, 
however, produce severe inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with some soothing or astringent powder, and with this end in view 



90 GENERAL THERAPEUTICS. 

nothing is better than chalk. Spender's hints 1 for making such an 
ointment are admirable. Finely levigated chalk is strewed into 
melted lard in a stone jar, the whole being stirred till it is cold. 
Then at first the smallest quantity of tar sufficient to make a brown- 
ish smear of color is added to the quantity of salve employed for 
use. This color can be successively deepened at will. Auspitz 
advises the use of the tars in a pure state, applied in very small 
quantities with a strong bristle-brush and well rubbed in. In com- 
bination with one of the most valuable of all substances for topical 
use in cutaneous therapeutics, viz., sulphur, tar enjoys a special 
reputation. The Wilkinson salve modified (q. v.) represents such a 
combination. 

Ichthyol, fish-oil, sulpho-ichthyolate of sodium or ammonium, 
introduced to the profession by Unna, is the distillate of a bitumi- 
nous and sulphurous deposit of petrified fishes and marine fossils 
found in Tyrol. Its chemical formula is C 26 H 36 S 3 Na 2 6 . It has a 
tarry appearance, odor, and consistency. It is soluble in water, 
partly so in ether and alcohol, and can be incorporated in any desired 
proportion with fat, vaseline, and lanolin. It has been used both 
pure and diluted ; and several proprietary articles (plasters, soaps, 
salves, and medicated cotton) are sold in the market. It has been 
used both at home and abroad in cases of leprosy, pruritus, acne, 
sycosis, eczema, psoriasis, and a number of other cutaneous disor- 
ders. 2 It is used in solutions and salves of from ten to twenty per 
cent, strength. As before stated, it is also administered internally, 
more particularly in the management of rheumatism, in doses ot 
from fifteen to twenty drops. It does not seem to have a disturbing 
effect upon the stomach. 

This substance has not yet been employed to an extent sufficient 
to establish its position firmly as a remedial agent in diseases of the 
skin. Personal employment of it in a series of different cases, the 
greater number being of eczema and lupus, led to the impression 
that it was not superior to tar in a therapeutic sense. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four-months' old infant sank into 
a state of stupor two hours after its head and limbs were smeared 
with a salve composed of one part of ichthyol to five of vaseline. 

A group of substances which occupy a therapeutical position infe- 
rior to the tars, but which serve an important end in the manage- 
ment of cutaneous diseases by the production of similar effects, are, 
carbolic acid, creasote, salicylic acid, benzol, naphthol, iodol, chrysa- 
robin, pyrogallol, resorcin, and jequirity. 

Resorcin in ointments of the strength of five to twenty per cent, 
serves as an antipruritic and alterative. Dr. Stelwagon reports an 

1 Practitioner, June, 1883, p. 402. 

2 See Bauraann and Schotten : Monatsh. f. Prakt. Derm., 1883. Unna : same journal, 1882 ; 
Deut. med. Zeit., 18S3. Samml. klin. Vort., 1885 ; Lorenz : Deut. med. Woch., 1885 ; Stelwagon 
and Piffard : Journ. of Cut, and Ven. Dis., 1886 ; Zeisler : Chicago Med. Journ.and Exam., 1886. 



GENERAL THERAPEUTICS. 91 

anodyne effect following its use. The same experimenter has modi- 
fied Ihle's formula by adding a drachm (4.) of resorcin to one to two 
drachms (4.-8.) of castor-oil, five minims (0.33) of Peruvian balsam 
and four ounces (128.) of alcohol, for use in alopecia and sebor- 
rhea of the scalp. It is a valuable parasiticide in lotions of the 
strength of from five to ten per cent. 

Naphthol, or /9-naphthol, as it is termed chemically, first intro- 
duced by Kaposi, has fairly retained its place in the list of efficient 
topical remedies. It is chiefly valuable in scabies, but has also been 
used in the management of eczema, psoriasis, and other exudative 
affections. Van Harlingen 1 has found it to answer well in seborrhoea 
of the scalp. Neisser has described renal disorders as resulting from 
its use in children, but MM. Josias and Nocard 2 report that in ordi- 
nary medicinal doses it is harmless. The fact that the naphthol 
preparations are odorless and do not stain the skin is to be set down 
in their favor. 

Jequirity (abrus precatorius), employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, 
has been used by Dr. Shoemaker 3 in the management of lupoid and 
other ulcers. One part of the cleansed, decorticated, and bruised 
grains, macerated for twenty-four hours, and reduced by rubbing in 
a mortar to a smooth paste, was added to sufficient water to make four 
parts. This emulsion was used for local application. 

Sulphur, employed popularly chiefly as a laxative or for the 
local treatment of scabies, has also a deserved reputation in cuta- 
neous therapeutics, as an external agent in a wide range of non-para- 
sitic disorders. Hebra ouce regarded it as valueless in eczema, but 
his opinions on this point are not now generally accepted. The pre- 
cipitated sulphur is to be preferred to the other compounds of the 
pharmacopoeia. It may be mechanically incorporated with salve- 
bases or chemically combined with vaseline and other petroleum pro- 
ducts, a process by which experiments have shown its therapeutic 
value is not increased. It is also applied after mechanical union 
with various substances as a lotion. It is irritating to the acutely 
inflamed skin, but much better tolerated in conditions of subacute or 
chronic exudation than the tars. 

Mercury and its compounds are of value in the local treatment 
of many disorders of the skin, syphilitic and non-syphilitic. Corro- 
sive sublimate as a parasiticide is of great importance in the treat- 
ment of several cutaneous disorders due to the presence of bacteria, 
as, for example, lupus vulgaris. Calomel, the oxides, iodides, and 
the ammonio-chloride, are chiefly used in the form of ointments, but 
the black wash, prepared with the mild chloride, is of great value 

i Amer. Journ. of the Med Sci., Oct., 1883. 2 Ann. de Derm, et de Svph., May, 1885. 

3 Lancet, Aug., 1884, p. 185. 



92 GENERAL THERAPEUTICS. 

in eczema. Piffard 1 has called attention to the fact that the officinal 
ointment of white precipitate is made with pure lard instead of as 
formerly with lard and wax ; and to this change, tending to hasten the 
absorption of the mercurial, he attributes some late failures with this 
admirable salve. Disagreeable dermatitis followed by scaling has 
been reported to follow its use in the strength of forty grains (2.66) 
to the ounce (32.) by Mr. W. E. Green, of London. 2 

Chloral-camphor and Phenol-camphor have value chiefly 
as antipruritics. The former is obtained by rubbing together the 
hydrate of chloral and gum-camphor (Bulkley) till they form a clear 
liquid of pungent odor. Phenol-camphor is made by gradually 
adding camphor to melted crystals of carbolic acid, a colorless liquid 
resulting having the fragrant odor of camphor without that of the 
acid. It is a useful local anesthetic agent, being insoluble in water, 
but freely soluble in chloroform, ether, and alcohol. 

Many Agents are employed upon the surface of the integument 
to produce in various degrees a Caustic or Destructive eifect. 
Among these may be named the thermo- cautery (Paquelin knife), 
galvano-caustic apparatus, the mineral acids and alkalies, ethylate of 
sodium, arsenic, chloride of zinc, several mercurial compounds, acid 
nitrate of mercury, bichloride of mercury, chloride of antimony, 
sulphate of copper, and nitrate of silver. Several of these sub- 
stances in weak solution are employed as milder agents for the pro- 
duction of irritative, or even various inflammatory, effects. To the 
latter class should be added iodine in tincture, chloroform, tartar 
emetic, croton oil, and cantharides. 

These destructive effects are of advantage in the treatment of dis- 
orders of the integument due to parasites, either animal or vegetable. 
Of those employed for this purpose, and not mentioned above, may 
be named petroleum and staphysagria, for the destruction of lice ; 
sulphur, styrax, and balsam of Peru, for the destruction of acari ; 
and sulphur and its compounds, and a number of derivatives from 
tar for the destruction of vegetable parasites. 

Counter-irritation over the Vasomotor Centres, as 
recommended by Crocker, is an efficient means of unseating fixed 
and obstinate cutaneous disorders. It may be produced by the action 
of sinapisms, blisters, or caustics over the region selected for such 
irritation. 

Hypodermatic Injection of various substances is a method of 
introduction of the latter within the body that is often not merely 
efficacious, but necessitated by the failure of the digestive processes. 
Such medicaments as arsenic, mercury, and pilocarpine are suc- 
cessfully employed in this way; and the widely known results of 

i Journ. of Cut. and Ven. Dis., Oct., 1886. 2 Brit. Med. Journ., 1865. 



GENERAL THERAPEUTICS. 



93 



the injection of Tuberculin, as originally devised by the eminent 
Robert Koch for lupus vulgaris and other forms of tuberculosis, 
need only to be mentioned in this connection. 

Electrolysis is an agent of the greatest value in the treatment 
of a large number of cutaneous affections, such as hirsuties, telan- 
giectases, molluscous tumors, warts, etc. It is accomplished by the 
aid of the galvanic battery in the manner described in this work in 
the pages devoted to the first of the disorders named. 

A variety of Surgical and other Appliances are found useful 
as adjuvants in the treatment of skin diseases. They may be em- 

Fig. 23. 



Irido-platinum needle. 
Fig. 24. 




Epilating forceps. 
Fig. 27. 




Piffard's grappling forceps. 



Fig. 28. 




Skin-grafting scissors. 



94 



GENERAL THERAPEUTICS. 



ployed to support, protect, or compress the surface, or merely to aid 
in the retention of dressings or external medicaments. Thus the 
ordinary roller bandage is applicable to many portions of the body ; 
the suspender, or suspensory bag, over the scrotum ; elastic or in- 



FlG. 29. 




Piffard's cutisector. 



Fig. 30. 



Fig. 31. 




Dermal curettes. 



Fig. 32. 




TIEMANN -CO-NY 

Hess's glass pleximeter. For observing the skin under pressure. 



Fig. 33. 



=ii- m^ 



:.".. 



Piffard's modification of Unna's comedo extractor. 
Fig. Si. 

O 'y4: OF REAL SIZE. 

Keyes's cutaneous punch. 

elastic stockings to the feet and legs ; kid, rubber, and thread gloves 
to the feet and fingers ; and various skull-caps, face-masks, and mit- 
tens are employed in the case of infants and children to protect 
affected surfaces from the dangers of scratching. 

It is an axiom in dermatology that a salve is worth far more to 
the patient when it is spread on muslin, and thus retained in contact 
with the skin, than when it is merely smeared or rubbed over the 
surface. It is this important feature which has doubtless contributed 
so largely to the reputation of Unna's salben-mulle, or salve-muslins. 



GENERAL THERAPEUTICS. 95 

In order to secure the retention of such salve-spread muslins in con- 
tact with the surface, the common muslin roller, which exercises 
more or less compression, is inferior to the light and more pervious 
cheese-cloth bandage. This is especially true when the dressing is 
made by the patient, who is, in general, far less expert than either 
the trained nurse or the physician. 

Apart from the surgical apparatus required for ablation of tumors 
or other severe operations, a number of instruments are required for 
the daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged 
spoons are for erasion of the surface, and should, for general use, 
have in each a fenestrum large enough to permit the escape of all 
collected substances from the floor of the spoon. The small-sized 
spoons, however, with solid bowl and sharp edges, largely used in 
Vienna, are preferable for use, especially about the face, in skin 
affections. 

Epilating forceps with easy springs and smooth blades meeting in 
perfect apposition. 

A set of Piffard's comedone extractors, provided at each extremity 
with a differently sized, minute, spoon-shaped and perforated bowl, 
the convex surface of which is pressed over the comedo with the 
orifice immediately over the black head of the plug. This is a great 
improvement over the old-fashioned comedo extractor shaped like a 
watch-key, and the discomfort to the patient is by its use greatly 
reduced. 

A set of half-inch and four-inch lenses for examining the surface 
of the skin. 

Needle-holders with light handles for firmly grasping needles for 
use in opening pustules, etc. The latter should be, some of them, 
flat, with a double-cutting edge, others rounded neatly on an emery- 
wheel, and all of them very carefully disinfected if used more than 
once. Too many precautions cannot be takeu in the practice of 
dermatology, with respect to the disinfection of all instruments made 
to penetrate the skin. 

Probes, exploring needles, fine dressing-forceps, delicate straight 
and curved scissors, and other instruments from the ordinary pocket- 
case of the surgeon, are indispensable. The instruments required for 
use in connection with the galvanic battery are enumerated in the 
chapter on hirsuties. 

For detection of different degrees of temperature at the surface, the 
author has employed for several years the thermo-electric differential 
calorimeter. The thermopiles of this apparatus act upon a galvano- 
meter needle suspended by a single filament of the cocoon of the 
silkworm, and it is thus as sensitive as is required for the most 
delicate observations. 



96 CLASSIFICATION. 



VII. 
CLASSIFICATION. 

The numerous attempts which have beeu made to classify diseases 
of the skin according to their nature and relations, have been a 
response to the generally recognized demand for a systematic arrange- 
ment of all scientific facts As regards dermatology, not only have 
these attempts been numerous and based upon different principles, 
but the results which they have accomplished have been in the 
highest degree divergent. No single classification yet devised has 
hitherto secured general acceptance. While it is certain that no one 
of them has been perfect and that each has exhibited defects, it is 
equally true that of the larger number each has possessed some merit 
of its own. No perfectly satisfactory classification of cutaneous dis- 
eases can be generally accepted till the knowledge of diseases of the 
skin has been greatly enlarged. 

One the most satisfactory of the systems thus far proposed is that 
of Hebra. By it cutaneous disorders are arranged in the following 
nine classes : 

Class I. Disorders of Secretion. 

Class II. Hyperemias. 

Class III. Exudations. 

Class IV. Haemorrhages. 

Class V. Hypertrophies. 

Class VI. Atrophies. 

Class VII New Growths. 
Class VIII. Neuroses. 

Class IX. Parasites. 

Since this classification was devised by Hebra, none has been pro- 
posed which compares in ingenuity with the arrangement by Auspitz 
of the diseases of the skin into natural groups. The principle of this 
classification is to place together those diseases and groups of diseases 
which present a clinical unity ; the general pathological process being 
the predominant characteristic for selection ; and individual patho- 
logical characteristics, such as symptoms, localization, anatomical 
peculiarities, etc., are only brought thus predominantly forward when 
coinciding with the real nature of the class, group, or disease in 
question. 1 

Auspitz's nine classes are: 1. Simple Inflammatory Dermatoses ; 
2. Angioneurotic Dermatoses ; 3. Neuritic Dermatoses ; 4. Stasis 

1 System d. Hautkrankheiten. Wien, 1881. 



CLASSIFICATION. 97 

Dermatoses ; 5. Hemorrhagic Dermatoses ; 6. IdioDeuroses ; 7. Epi- 
dermic! oses ; 8. Cliorio-Blastoses ; 9. Dermatomy coses. 

Under these classes, by the aid of divisions and subdivisions, an 
elaborate scheme is presented, which embraces fully not only all 
cutaneous diseases, but all pathological processes recognized in the 
skin. This system, accepted with modifications by Hans Hebra, 1 has 
unquestionably been followed by a greater advance in the nosology 
of cutaneous medicine than any of those which have been proposed 
since Hebra first offered his. 2 

Auspitz's classification is, however, open to various objectious on 
the part of the student of dermatology. It is elaborated to the 
extent of setting the names of some diseases in more than one family ; 
and is, hence, confusing to the beginner. It is better adapted to the 
needs of the expert than of the young student, for it introduces to 
the study rather of morbid processes in the skin than of the com- 
plexus of those processes which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, 
or pathological ; whether it be based on the processes actually occur- 
ring in the skin, or on those deeper factors and forces operating cen- 
trifugally upon the skin, and on which that organ depends for all its 
functions and even its existence; whether it proceed etiologically 
from the causes which are immediate, or those which are remote, it is 
easy to see that, as knowledge in each of these directions "enlarges, 
the exact position of any one disease in any given classification must 
be rendered insecure. Never was this observation more suggestive 
than at this day, when the pathogeny of numerous skin disorders is 
revealed in the light thrown on the subject by the discovery of new 
and hitherto unknown inferior organisms. 

Indeed, to this last cause, awakening grave doubts as to the pre- 
cision of much that was once esteemed fact, may be attributed the 
declining interest in the general subject of classification of diseases of 
the skin. The earnest discussion of this theme has been practically 
deferred by common consent to a date when the questions thus sug- 
gested can be more satisfactorily answered. Several recent writers 
have actually contented themselves with an alphabetical arrangement 
of the names of skin diseases, as an order useful simply for reference. 

The classification recognized in the arrangement of subjects in this 
work is that adopted by the American Dermatological Association 
August 29, 1878, and revised by the same body August 28, 1884. 
It is a modification of the scheme first proposed by Hebra. The 
Association, which first propounded this American classification, is 
now considering the subject of a further revision of its nomenclature 
and arrangement of skin diseases. Pending its decision on many 
points, it has for a time employed a provisional schedule with an 
alphabetical list of all cutaneous affections. Viewing the rapid 

1 Die Krankh. Veranderung. der Haut. Braunschweig, 1884. 

2 An exceedingly ingenious and comprehensive scheme of classification of diseases of the 
skin, embracing most of the principles upon which the best of previous classifications were 
based, was presented by Dr. E. B. Bronson, of New York, at the meeting of the American Der- 
matological Association, in August, 1887. 

7 



98 



CLASSIFICATION. 



changes made annually in the knowledge of many subjects connected 
with diseases of the skin, it is generally conceded that at this time 
it is proper to defer assigning a definite position in pathology to a 
large number of recognized affections. 

While, however, scientific men are cautious in committing them- 
selves to definite conclusions with relation to this subject, it is ex- 
ceedingly undesirable to relegate the student of dermatology and the 
practitioner who for the first time begins its systematic investigation, 
to a list of names in alphabetical arrangement. The latest classifica- 
tion of skin diseases proposed by the recognized experts of derma- 
tology in America has been, therefore, accepted in a modified form 
for the purposes of this treatise. For more than twelve years it has 
been the basis of dermatological study in the leading medical schools 
of this country. It is not claimed to be either complete or without 
defects. It stands, however, to-day as the most convenient nosologi- 
cal scheme available for a text-book of cutaneous medicine, and will 
doubtless be revised in the future as occasion shall require. 

Classification of Diseases of the Skin adopted by the 
Ameejcan Dermatological Association. 



Class I. Disorders of the Glands. 

1. Of the Sweat Glands. 

Hyperidrosis. 

Sudamen. 

Anidrosis. 

Br o uridrosis. 

Chromidrosis. 

Uridrosis. 

2. Of the Sebaceous Glands. 

Seborrhcea : 

a. oleosa. 

b. sicca. 
Comedo. 
Cyst: 

a. Milium. 

b. Steatoma. 
Asteatosis. 

Class II. Inflammations. 

Exanthemata. 
Erythema simplex. 
Erythema multiforme : 

a. papulosum. 

b. bullosum. 

c. nodosum. 
Urticaria. 

pigmentosa. 
Dermatitis : l 

a. traumatica. 

b. venenata. 

c. calorica. 

d. medicamentosa. 

e. gangrenosa. 



Erysipelas. 

Furunculus. 

Anthrax. 

Phlegmona diffusa. 

Pustula maligna. 

Herpes simplex. 

Herpes zoster. 

Dermatitis herpetiformis. 

Psoriasis. 

Pityriasis maculata et cir- 

cinata. 
Dermatitis exfoliativa. 
Pityriasis rubra. 
Lichen : 

a. planus. 

b. ruber. 
Eczema : 

a. erythematosum. 

b. papulosum. 

c. vesiculosum. 

d. madid ans. 

e. pustulosum. 
/. rubrum. 

g. squamosum. 
Prurigo. 
Acne. 

Acne rosacea. 
Sycosis. 
Impetigo. 

Impetigo contagiosa. 
Impetigo herpetiformis. 
Ecthyma. 
Pemphigus. 



1 Indicating affections of this class not properly included under other titles. 



CLASSIFICATION 



99 



Class III. Hemorrhages. 

Purpura : 

a. simplex. 

b. hemorrhagica. 

Class IV. Hypertrophies. 

1. Or Pigment. 

Lentigo. 
Chloasma. 

2. Or Epidermal and Papillary 

Layers. 
Keratosis : 

a. pilaris. 

b. senilis. 
Molluscum epitheliale. 
Callositas. 

Clavus. 

Cornu cutaneum. 

Verruca. 

Verruca necrogenica. 

Nsevus pigmentosus. 

Xerosis. 

Ichthyosis. 

Onychauxis. 

Hypertrichosis. 

3. Of Connective Tissue. 

Sclerema neonatorum. 
Scleroderma. 
Morphoea. 
Elephantiasis. 
Rosacea : 

a. erythematosa. 

b. hypertrophica. 
Framboesia. 

Class V. Atrophies. 

1. Of Pigment. 

Leucoderma. 
Albinismus. 
Vitiligo. 
Canities. 

2. Of Hair. 

Alopecia. 

Alopecia furfuracea. 
Alopecia areata. 
Atrophia pilorum propria. 
Trichorexis nodosa. 

3. Of Nail. 

Atrophia unguis. 

4. Of Cutis. 

Atrophia senilis. 

Atrophia maculosa et striata. 



Class VI. New Growths. 

1. Of Connective Tissue. 

Keloid. 

Cicatrix. 

Fibroma. 

Neuroma. 

Xanthoma. 

2. Of Muscular Tissue. 

Myoma. 

3. Of Vessels. 

Angioma. 

Angioma pigmentosum et 

atrophicum. 
Angioma cavernosum. 
Lymphangioma. 
4. 

Phinoscleroma. 
Lupus erythematosus. 
Lupus vulgaris. 
Scrofuloderma. 
Syphiloderma : 

a. erythematosum. 

b. papulosum. 

c. pustulosum. 

d. tuberculosum. 

e. gummatosum. 
Lepra : 

a. tuberosa. 

b. maculosa. 

c. ansesthetica. 
Carcinoma. 
Sarcoma. 

Class VII. Neuroses. 

Hyperesthesia : 

a. pruritus. 

b. dermatalgia. 
Anaesthesia. 

Class VIII. Parasitic Affections. 

1. Vegetable. 

Tinea favosa. 
Tinea trichophytina : 

a. circinata. 

b. tonsurans. 

c. sycosis. 
Tinea versicolor. 

2. Animal. 

Scabies. 

Pediculosis capillitiL 
Pediculosis corporis. 
Pediculosis pubis. 



In the pages which follow it is seen that many modifications of 
this classification have been necessitated by later investigations in 
cutaneous medicine. 



DISEASES OF THE SKIN 



CLASS I. 

DISORDEKS OF THE GLANDS. 

In this class of disorders are grouped all the functional disorders 
of the sweat or coil -glands, the sweat pores, and the sebaceous 
glands. These disorders may be betrayed in quantitative or quali- 
tative changes in the secretion, or in retention of the latter in the 
whole or in a part of the secretory apparatus. When a disease of 
the skin ceases to be purely functional in type, and is accompanied 
by an exudative process, glandular or peri-glandular in situation, 
such disease is properly classed with another and in this particular 
related group of affections. 

1. Of the Sweat Glands. 
Hyperidrosis. 

Gr. virepj in excess ; vdup, water. 

(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, 
Hyperhidrosis.) 

Statistical frequency in America, 0.265. 

Hyperidrosis is an exaggerated quantitative effusion of sweat, the secretion accu- 
mulating in visible drops upon the surface of the skin. 

Symptoms. — This condition may be physiological as the result of 
active exertion in a medium of high temperature ; or it may be patho- 
logical in character, and in the latter case be either general or partial. 

General sweating to a pathological extent occurs chiefly in the 
obese, but also in those who are the subjects of constitutional disease 
(phthisis, the various febrile disorders, etc.). It is the fertile source 
of the various forms of intertrigo, sudamina, and miliaria. Local 
hyperidrosis is the exaggerated quantitative effusion of sweat limited 
to certain definite portions of the skin, as the palms, soles, dorsa of 
the hands and feet, the interdigital spaces, the genitals, the axilla?, 
and temples. In such cases the secretion occurs moderately or greatly 



102 DISEASES OF THE SKIN. 

in excess, varying in this respect somewhat in different degrees of 
temperature, and of rapidity of the circulation ; is occasionally, but 
not commonly, accompanied by fetor ; and always occurs to a marked 
extent. It may involve one or both sides of the body, being gener- 
ally symmetrical at the extremities, and asymmetrical upon portions 
of the face. 

Its topical expression may be studied in the hands, which are con- 
tinually moistened, clammy, or dripping with fluid within a brief 
time after the most careful drying of the parts. In the case of a 
woman, the instincts of whose sex prompt her to take such precau- 
tions, the dress is constantly protected from contact with the mace- 
rated palms by a handkerchief or similar article which is always in 
readiness. The disadvantages thus arising in individuals of both 
sexes who are engaged as tradespeople, artists, hand- workers, etc., 
can be readily estimated. In women of social position, no small 
complaint is made of the disagreeable result produced after wearing 
kid gloves for even a short time, the material of which is soon soiled 
by its complete saturation with the secretion from the skin. 

With and without this local excess, occurs the hyperidrosis of the 
feet, aggravated by the mechanical force of gravity and the need of 
constant covering. The stockings and the leather of the boots, shoes, 
or gaiters are saturated with the secretion, and become rapidly sub- 
ject to chemical alteration. There is usually an offensive odor of the 
region, originating partly in the primary fetor of the secretions them- 
selves, and partly in the subsequent chemical decomposition of the 
latter, rapidly progressing under the influence of the soiled and often 
stinking investments of the feet. 

The integument, constantly macerated, may become both painful 
and tender ; very rarely there is vesiculation or exfoliation of patches 
of sodden epidermis. When the genitals are involved, especially in 
the male, erythema and intertrigo are the frequent results. 

Etiology. — The disease may be in rare cases congenital. In others 
it is associated in one person with disorders not apparently related to 
it. In the case of a hospital patient recently examined, a woman, 
twenty-four years of age, was affected with severe tylosis of the feet, 
from which were exfoliated extensive lamellated casts of the soles. 
She also had typical hyperidrosis of the hands. 

In no portion of the nervous system has a localized centre for 
excito-sudoral or inhibitory effects been recognized. Traumatisms, 
gliomata, gummata, scleroses, and other lesions affecting the cerebrum, 
medulla, cord, ganglia, and trunks of the sympathetic nervous sys- 
tem have been followed by local and general hyperidrosis, but they 
have all repeatedly failed to induce such morbid sudoral symptoms, 
while a fit of anger or sudden fright has been as conspicuously effec- 
tive as any. In short, the predominant influence of the nervous 
system in an etiological sense must be admitted here as in physio- 
logical sweating : and to the sympathetic branches of that system must 
be assigned the greater influence for the most cases. A paralysis or 
paresis of the sympathetic is held to explain the occasional coinci- 



HYPERIDROSIS. 103 

deuce of pulmonary and cardiac disorders, with either general or 
partial excessive sweating. Compression of the sympathetic by 
adenomata, aueurisms, carcinomata, etc., has been followed by marked 
symptoms of this disorder. The disease is encountered in individuals 
of both sexes, and in all ages and degrees of general health, as also 
in those who are and those who are not careful as to cleanliness. 
There is reason to believe that the facial asymmetrical hyperidroses 
associated with migraine, neuralgias, hemicrania, etc., are etiologically 
and pathologically distinct from the similar symmetrical affections of 
the hands and feet. The latter certainly occur with conspicuous fre- 
quency in young women who are the subjects of hysteria, chloro- 
anasmia, some form of dysmenorrhea, or cardiac trouble. In one 
young woman under the author's observation, there was an habitual 
pulse of fifty-five to the minute without dicrotism, the patient being 
in other respects well. 

Pathology. — Robinson, who has examined a number of sections 
from the palm of the hand, failed to detect any abnormal feature 
either in the glands or the epithelium. The disorder is to be regarded 
as purely functional ; and any anatomical changes in the coil-glands 
or sweat-pores are probably accidents of such derangement of func- 
tion. 

Treatment. — When universal, hyperidrosis is to be treated inter- 
nally by the aid of such remedies as are indicated by the general 
condition of the patient. The various ferruginous tonics, mineral 
acids, arsenic, strychnia, quinine (the latter particularly when, as is 
often the case, a malarial affection is responsible for the disorder), 
and ergot, with both belladonna and atropine, are all of unquestion- 
able value. Even though but temporarily serviceable, belladonna 
and atropine are well used at the outset of most cases. Aconite, 
jaboraudi and pilocarpine, white agaric (agaricine is recommended in 
doses of one sixth of a grain (0.011), repeated as required), carbolic 
and salicylic acids may be named as in the second rank. 

External treatment is often promptly efficacious, and can rarely be 
neglected in any case. The simplest method is by wiping, not wash- 
ing, the surface until it is dry, and applying the dusting-powders, 
such as lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, 
hydrate of chloral one part to five or six of starch, and starch itself, 
the chief objection to the latter beiug its tendency to form cakes or 
rolls after its union with the sweat. Alternately with these, or in 
lieu of them, baths or lotions maybe employed, aqueous or alcoholic, 
and medicated with corrosive sublimate, tannic acid, ferric sulphate, 
naphthol (Kaposi), turpentine, zinc sulphate, alum, permanganate of 
potassium, or the sea salt now sold in packages for domestic use. 
Dr. G. H. Fox 1 advises a lotion containing one part of quinine to 
one hundred of alcohol. Van Harlingen recommends the use of 
juniper tar or carbolic acid soap with the bath, as alone sufficient to 
relieve some cases. 

1 Journ. of Cutan. and Ven. Dis., 1885, p. 24. 



104 DISEASES OF THE SKIN. 

For hyperidrosis of the feet, the treatment by the method of 
Hebra has, deservedly, high repute. It consists in neatly and com- 
pletely enveloping the entire foot and toes separately, after thorough 
washing and drying, in strips of cotton cloth over which is spread 
to the thickness of the blade of a common knife, the unguentum 
diachyli albi elsewhere described. This latter is made by boiling 
one part of the best litharge with about four parts of pure olive oil, 
to which a little water is added while the materials are stirred to- 
gether over a slow fire. The parts are well bandaged, and the patient 
either remains subsequently at rest or pursues his vocation, wearing 
over the feet, shoes and stockings which have not been previously 
used. In twenty-four hours, the feet are re-dressed without washing, 
after dry rubbing with charpie and a dusting powder. This is re- 
peated daily for ten to twenty days, after which a dusting powder 
(boric acid) may be substituted for the local dressing. A parchment- 
like desquamation of the epidermis in thick, yellowish-brown lamellae 
occurs, beneath which an epidermis is formed, new and at first tender, 
but apparently normal. When the latter has lost its tenderness, the 
feet are for the first time washed with water. In case of failure, the 
routine of treatment is, as often as necessary, again carried out. It 
is scarcely necessary to add that no ill effects are known to have re- 
sulted from the therapeutic measures adopted for checking a local 
hyperidrosis. 

For the diachylon salve may be substituted tar, ichthyol, or naph- 
thol ointments. Fredericq employs finely pulverized tartaric acid, 
applied at first with some caution, and always in small quantities. 
Stewart first bathes the feet in hot water and then soaks them for a 
few moments, aud once only, in a solution of the permanganate of 
potassium, four to six grains to the ounce (0.266-0.4 to 32.), after 
which, the plaster selected for use may be applied as directed above. 
Legoux orders pediluvia of tar water twice daily, for three days, 
followed by a painting of the feet with a solution of the perchloride 
of iron. Morrow 1 recommends foot-baths in the extract of pinus 
canadensis, followed by the application of boric acid, or salicylic 
acid, mixed with lycopodium. Lastly, Brandon, experimenting on 
the permeability of the skin to ethers and gases, claims to have 
solved the problem of local treatment with a " liquor anti-hidror- 
rhoicus," prepared from the chloric ethers. 

Prognosis. — The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
recur, be promptly amenable to treatment, or prove obstinate to all 
therapy. Dr. Myrtle 2 reports the case of a male patient, seventy- 
seven years old, who sweat to death after repeated recurrences of 
severe hyperidrosis, and after temporary relief from the use of 
Fowler's solution. 

1 See bis resume of this subject in tbe Journ. of Cutan. and Ven. Dis., vol. v. p. 68. 

2 Medical Press, Feb. 25, 1886. 



SUDAMEN. 105 

Sudamen. 

Lat. sudor, sweat. 

(Miliaria Crystallina.) 

Statistical frequency in America, 0.216. 

Sudamina are discrete, superficially seated, millet-seed sized and larger, translu- 
cent vesicles, resembling seed-pearls. 

Symptoms. — In this disorder the lesions are thickly agglomerated, 
but discrete, transitory, and translucent, pin-point sized vesicles, 
resembling dew-drops or seed-pearls, upon the surface of the skin, 
often requiring the touch to define their real character. They are 
usually limited to certain regions of the body, as the trunk, and here 
more generally upon the face and sides of the belly, and the iliac 
regions, though they may occur upon any part. Their course is rapid, 
both in evolution and involution, and their sequela? are exceedingly 
delicate desquamative flakes, the thin roof-wall which originally cov- 
ered the sweat-drops having been lifted from the superficial stratum 
of the horny layer of the epidermis. They contain each a droplet of 
sweat, which is removed by evaporation. They are usually preceded 
by an attack of pruritus, and may follow the hyperidrosis of sys- 
temic debility, enteric and continued fevers, phthisis, inflammatory 
rheumatism, pneumonia, and other asthenic conditions. They may 
also result from violent exercise, the elevated temperature of the 
summer season, flannel underclothing, vapor baths, and the appli- 
cation of wet and hot cloths to the surface of the skin. 

The lesions are the result of the accumulation of sweat between 
the most superficial layers of the stratum corneum, in high tempera- 
tures of the body, or of the medium by which it is surrounded, and 
usually in states of adynamia. They may hence occur at all ages, 
and in both sexes. 

Robinson states that they form rapidly on the face of laundresses, 
and in women from the thirty-fifth to the fiftieth year of life, where 
also they are isolated and disappear slowly. 

Three forms of sudamina have been described : (a), sudamina 
alba ; (b), sudamina rubra ; and, (c), sudamina crystallina. The 
last-named is the only form to which the term sudamen is properly 
applied, since it alone of the three designates a purely functional 
derangement of the sweat- secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to lesions 
where there is maceration of the vesicular wall and the contents be- 
come opalescent. This is rare. The second term, sudamina rubra 
(miliaria rubra, miliaria papulosa, lichen tropicus, " prickly heat "), 
is applied to inflammatory lesions which may accompany profuse 
sweating. These are numerous pin-point to pin-head sized vesicles 
surrounded by a reddish halo, or papules of the same dimensions, or 
the two lesions commingled, almost invariably accompanied by 



106 DISEASES OF THE SKIN. 

hyperidrosis, though the latter may be absent in high temperatures. 
The marked tingling, pricking, and burning sensations by which 
they are accompanied are often in the highest degree distressing, and 
may solicit rubbing of the affected part, though the scratching elicited 
by severe pruritus is not common. Minute crusts may form after 
vesicular rupture. The attack may be mild or quite severe, and last 
for a few days, or for as many weeks or months, as the result of 
continuous aggravation, or of the production of new crops of lesions 
after each recurrence of the cause. It is not rarely complicated in 
obese individuals by all varieties of intertrigo and eczema. 

The sudamina crystallina are, however, the sole lesions which may 
be properly considered in this class of affections. They are always 
free from all inflammatory symptoms, presenting a limpid, dew-drop- 
like aspect that is characteristic. 

Etiology. — The disease is induced by excessive sweating ; often in 
consequence of an elevated temperature ; also, however, as a result 
of a systemic asthenia, as indicated above. 

Pathology. — Dr. Robinson has studied the anatomy of the suda- 
men with special care. Its contents are pure sweat without admix- 
ture of lymphoid corpuscles. The fluid collects between the laminae 
of the deeper part of the corneous layer. The author supposes a 
rupture of the wall of the sweat-duct, but with our present knowl- 
edge of the anatomy of this part of the skin, we can see in his 
illustrations the obliterations merely of the sweat-pore by a sudden 
effusion of watery fluids toward the epidermis, which pass with 
moderate pressure through the wall-less sides of the pore into the 
spaces between the epithelial cells, where a chamber is readily formed. 

This is made clearer by the author's exact description of actual 
dilatation of the duct of the coil-gland, where there is " not an escape 
of sweat into the neighboring tissue/' which he recognized in the 
corium. The sudamina exhibiting this peculiarity appear on the 
face, chiefly of women. 

Diagnosis. — No difficulty can arise in making a diagnosis, if the 
peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents ; all bullous lesions are larger ; or 
seated on an engorged base ; or lack the limpid clearness of the 
sudamen, because, however transparent the contents, they are mostly 
covered by a thicker and less transparent roof. The halo about the 
lesions of miliaria rubra, or their rosy-pinkish shade will determine 
their character. In varicella the lesions are chambered. 

Treatment. — Only the simplest treatment is required. Alkaline 
and bran baths may be taken, of the temperature most grateful to the 
skin, which may afterward be dusted with one or several of the dust- 
ing powders, such as starch, lycopodium, or boric acid, named in the 
chapter on General Treatment of Cutaneous Diseases. The general 
treatment is that indicated by the condition of the patient. 

Miliary Fever, " Sweating Sickness," or the suette miliaire of 
the French, is an epidemic disorder, accompanied by sweating and a 



ANIDROSIS. 107 

cutaneous exanthem. Pineau 1 gives a description of the disease as 
it occurred in epidemic form in the island of Oleron, where, of one 
thousand patients affected, between one hundred and fifty and two 
hundred perished. The eruption appeared in the form of hyperaemic 
maculse, disappearing under pressure, after which there rapidly 
formed myriads of reddish or whitish, grouped, unequally sized, and 
acuminate pajDules, rising from a whitish and macerated surface. 
Among these were interspersed lesions of sudamina. The region of 
the face was not spared, and the conjunctivae were occasionally 
affected. In the course of from two to four days, pin-head to bean- 
sized, varioliform but non-umbilicated pustules formed in the site of 
some of the papules, the contents of which disappeared by resorption, 
the final lesions presented being large, flat, reddish papules, the skin, 
of the face particularly, becoming generally reddened and swollen. 
In the course of from ten to twelve days, general desquamation 
ensued with large palmar and plantar losses. Relapses occurred in 
some cases with general redness of the surface, or with crops of red- 
dish plaques, or yet again with the occurrence of furuncles. The 
sensations were those of myriads of needles thrust into the skin. 
The exanthem was accompanied in some cases by fever, and in others 
not. In fatal cases death resulted from exhaustion. 

Geber, however, and other writers believe that the lesions described 
are not peculiar to any special disease ; and deny the possibility of 
an independent miliary fever. 



Anidrosis. 

Gr. a, privative ; vdop, water. 

Statistical frequency in America, 0.009. 

This name is properly applied to those morbid conditions where no sweat is 
secreted from the surface of the body. The word Hypohidrosis is more exactly 
used to designate a relative, general or partial decrease in the quantity of the 
sudoral fluid. The former term is, however, often used to include the latter. 

Complete anidrosis occurs naturally only when the sudoral appa- 
ratus has been involved in destructive or other changes in the skin 
(scars, atrophy, etc.). 

Diminution in the quantity of sweat excreted, or its complete sup- 
pression, whether general or local, is a symptom of several disorders, 
but as a separate cutaneous affection has no existence. It is suffi- 
ciently common in many cutaneous diseases, as, for example, ichthy- 
osis, psoriasis, and some forms of eczema. But in these, the symp- 
tomatic character of the anomaly is illustrated by the well-known 
fact that when the skin is relieved of these cutaneous troubles, the 
function of sweat secretion is restored. Similarly, in neuralgias and 
certain forms of paralysis, a circumscribed and temporary anidrosis 

1 Archiv. gener. de Med., Jan. 1882, p. 25. 



108 DISEASES OF THE SKIN. 

may be the local expression of the nervous disturbance, precisely as 
in the case of the asymmetrical hyperid roses. Lastly, there are 
individuals exhibiting the idiosyncrasy of sweating either not at all 
or quite imperceptibly in elevated temperatures, phenomena which 
should be ascribed rather to peculiarities in the equilibrium of the 
heat-exchanging forces, than to congenital deficiency of the sweat- 
glauds. 

According to Geber, Strauss and Bloch regard the occurrence of 
hypohidrosis and anidrosis as differential diagnostic symptoms of 
diffuse myelitis and poliomyelitis as against cerebral paralysis. 

Treatment. — The measures capable of stimulating the sweat secre- 
tion are : the ingestion of water in quantity by the mouth, the ex- 
ternal application of heat in a dry or moist atmosphere, and the use 
of jaborandi or pilocarpine by the mouth or hypodermatic injection. 
In the anidrosis accompanying cutaneous disease, the indication is 
always primarily for the relief of the latter. 



Bromidrosis. 

Gr. (3po)/iog } a stench ; vSup, water. 

(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat.) 

Statistical frequency in America, 0.090. 

Symptoms. — Here the perspiration is effused in such a state that it 
can be immediately perceived to possess an unusual odor, or, as 
Hebra taught was the case with the majority of patients, to be rapidly 
changed to that condition. It is often associated with hyperidrosis, 
or may occur quite independently of the latter, and like the latter 
also be either general or partial. The odor may be either agreeable 
or disagreeable, having been in various cases compared to that of 
several flowers and fruits, as well as to that of several stench-emitting 
animals. In this respect the sweat presents a striking analogy to 
the urine, with which it sustains a close and well-recognized physio- 
logical relation. 

General bromidrosis may be physiological, as in the case of indi- 
viduals of the African race, or in those of dark skins who are pro- 
fusely sweating during labor or in exalted temperatures. General 
pathological bromidrosis is rare. The odors emanating from the 
person in ulcerating syphilodermata, smallpox, and other general 
disorders, may, in certain cases, be associated with the sweat secre- 
tion, but in others doubtless are connected with the decomposition of 
pathological products of the inflammatory process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess, and its immediate evaporation 
prevented, as in the axillae, groins, feet, ano-genital, inter- and infra- 
mammary regions. In a qualitative sense, every degree of odorous- 
ness is noted, from that which is merely slightly agreeable or offen- 



CHROMIDROSIS. 109 

sive, to the most intolerable stench. When complicated by a seborrhoea 
in situations where the parts are not only warm, moist, and covered 
by clothing, but also subjected to friction and long uncleansed, the 
most intolerable and nauseous fetor is perceived. 

Sweat may be effused in a normal condition, upon and within the 
articles of clothing worn, and subsequently generate a stench by 
chemical changes both in the clothing and the fluid by which that 
clothing is saturated. This should never be forgotten in the prac- 
tical management of any case. 

Etiology and Pathology. — Thin has recognized micrococci (bacterium 
foetidum) in sweat obtained from the feet. Parkes concludes that 
the sole cause of the disease is covering the foot, as soldiers with 
uncovered feet do not suffer. It is occasionally due to emotional 
causes, to chronic alcoholism, or to the gouty state. 

Treatment. — The treatment of bromidrosis is, in general, that of 
hyperidrosis already described. Thin 1 has successfully employed 
stockings and cork soles dried thoroughly, after saturation for hours 
in a jar containing a solution of boric acid. The efficacy of this he 
ascribes to the fact that the odor is the result of the development in 
the secretions of the bacterium foetidum. An ointment is also em- 
ployed by him for similar purposes, produced by making a solution 
of the acid in glycerin and incorporating it with a fatty basis of 
white wax and almond oil, making thus a " glycerated cream of 
boric acid." Armiugaud, of the French Academy, has reported 
excellent results following the subcutaueous injection of three grains 
(0.20) of the nitrate of pilocarpine, eight of which operations were 
successful in reducing the abnormal sweating fetor. Clement Haw- 
kins 2 finely triturates fifteen grains (1.) of the red oxide of lead, and 
to this adds gradually one ounce (32.) of Goulard's extract. This is 
used as a lotion following a nightly foot-bath containing an ounce 
(32.) of alum. 

Fox (1. c.) advises a one per cent, solution of chloral, or potassium 
permanganate as a topical application. 

Internally the sodium salicylate has been employed with success 
in five grain (0.33) doses. 

Ohromidrosis. 

Gr. xptifia, color ; vdop } water. 

Statistical frequency in America, 0.005. 

By this term is indicated the condition in which effused sweat exhibits an 
abnormal color, yellowish, reddish, greenish, or blackish. The term Cy anhi- 
drosis has been employed to indicate blue sweating. 

In these cases there has been usually a copious secretion of fluid. 
Authors have variously attributed the color to the presence of com- 
pounds of phosphorus, iron, cyanogen, indican, Prussian blue, 

1 Practitioner, December, 1881, t». 2101. 

2 British Medical Journal, May 7, 1881. 



110 DISEASES OF THE SKIN. 

baBmatin, chromogen, and even to parasitic vegetations upon the 
surface. Women, much more often than men, exhibit the free 
deposit of pigment upon the skin, and, in view of the admitted 
rarity of chromidrosis the suspicion arises that in some of the cases 
reported there was free pigmentation of the surface by which the 
fluid exuded was immediately stained or colored. Duhring reports 
a single case of red sweating in a vigorous male patient. Usually, 
however, the phenomena occur in persons who betray some evidence 
of impairment of other organs than the skin, or who are debilitated 
in general health, thus furnishing an indication for their treatment. 

Babesiu, 1 of Pesth, reports some interesting cases of this disorder, 
which appear to have been produced by the presence of bacteria. In 
four patients, three of them women, there was considerable pruritus 
with pale-red to blood-red sweat ; in one, the skin and hairs were 
reddened. The axillse were the source of this colored perspiration. 
In all the cases microscopical examination revealed similar changes. 

The hairs of the axillse were thin, pale red, brittle ; and surrounded 
with a colloid-looking, rusty, or bright-red sheath, in places of con- 
siderable thickness and having a rough surface. It consisted of red 
masses, presenting a radiating striation, more or less confluent, 
apparently proceeding from fibres of the cortex of the hair or from 
some broken part of its surface. The radiating striation was found 
to be due to the aggregation of round or ovoid bacteria, scarcely a 
micromillimetre in diameter, which were united in zoogloea masses 
by a reddish, intermediate substance. Nodular swellings on the hair 
were produced by the infiltration of the organism between the sepa- 
rated fibrils. The roots of the hair were free from bacteria. The 
red tint of the sweat was found to depend upon numerous roundish 
masses of zoogloea. 

T. C. Fox 2 also has reported two cases in which a deep bluish- 
black pigment was exuded upon the skin of the circumorbital 
region. The amorphous granules were found insoluble in almost all 
hot or cold reagents, but displayed a deep blue color when moistened 
with glycerin and purplish hue when dissolved in hot sulphuric acid. 

The hypothesis, that certain cases described as chromidrosis are 
really instances of mechanical washing of pigment to the surface in 
the profuse sweating of the debilitated, is strengthened by the phe- 
nomena of simultaneous hair coloration. Thus, Prentiss 3 reports 
the case of a young woman affected with acute cystitis and passing 
purulent urine, whose hair, under the influence of profuse sweating 
induced by the action of pilocarpine, changed speedily from a light 
blond to a nearly jet-black hue. At the meeting of the American 
Dermatological Association, in 1881, the author exhibited hairs of a 
middle-aged man which had changed in a night from a grayish-white 
to a greenish and yellowish-brown hue ; and in commenting upon 
these, Dr. "White, of Boston, stated that he had observed several 
similar cases of hair coloration as the result of profuse sweats. 

In the year 1884 this same observer reported to the Association 

i Lancet, 1862. 2 Med. Fress and Circ., Jan. 1, 1881. 3 Phila.JMed. Times, July 2, 1881. 



URIDROSIS. Ill 

the case of a workman in a sugar refinery, whose sweat from the left 
side of the body was of a bright yellow color for several months, and 
where, though sought for, no bacteria were discovered. 

In a case observed by Bergmann a mycelium was recognized 
which was subsequently cultivated on paste. Eberth has recognized 
bacteria in both normal and yellow sweat. 

Le Roy de Mericourt, first to name this disorder, 1 has also 2 de- 
scribed a case of rosy sweating in an infant. 

F6reol believes that in these cases there is actually an absence of 
sweat and prefers to call the disorder chromocrinia. 

In all cases, before accepting statements of patients as to the exist- 
ence of symptoms of this character, it is needful to eliminate the 
possibilities of deceit and accident. Coloring matters received upon 
the hands may be, either in wilfulness or ignorance, transferred to 
the surface of the body. 

Greenish Sweating, due to the presence of copper in the sys- 
tem, has been reported in a few instances. The author has observed 
one case where the effect was produced by the copper plate of an 
electrode in contact with an abraded surface of the skin. 

Phosphorescent Sweating is reported to have occurred after 
the eating of phosphorescent fish and the ingestion of phosphorus 
for medicinal purposes. 

The treatment of these several conditions is that of the general 
state of the patients exhibiting these symptoms. 

Uridrosis. 

Gr. ovpov, urine ; vdop, water. 

Uridrosis is that condition in which some of the constituents of the urine, chiefly 
urea, are excreted in excess with the sweat. 

While a small amount of urea is to be recognized in normal sweat, 
it may, under peculiar conditions, be increased, and, together with 
urinary salts deposited upon the skin surface after evaporation of 
the exuded fluid. Such symptoms have usually occurred either as 
the result of grave constitutional affections, such as cholera, or of 
organic renal disease, accompanied by ansemia ; or of the ingestion 
of jaborandi. In a few cases the symptoms have been presented in 
individuals who were apparently in good health. The salts of the 
urine appeared upon the skins of these patients in the form of minute 
lamellae, or a fine powder of whitish color and crystalline aspect. 
In some cases reported the symptoms have been noted to precede by 
a few days a fatal issue. 

The constantly adjusted equilibrium between the sweat and the 
urinary excretion would explain, for cases of a mild type, temporary 

1 Arch. gen. de Med., November, 1857, 2 La France Medic, 1884. 



112 DISEASES OF THE SKIN. 

augmentation in the urea formed in the sweat of unusually free 
diaphoresis. Geber supposes that decomposition products, such as 
the carbonate of animoniun, possibly aided by the volatile fatty 
acids, may in part account for these conditions. 

Dysidrosis. — Under the names Dysidrosis and Cheiro-porn- 
pholyx, Tilbury Fox and Hutchinson, of London, respectively, 
described cases in which deeply imbedded, pin-head sized, acuminate, 
primarily translucent vesicles occur upon the palmar and inter-digital 
surfaces. Both in consequence of coalescence and increase in size, 
bullae may subsequently form an inch or more in height, filled with 
an alkaline or slightly acid fluid supposed to be sweat. Partial 
absorption occurs if the lesions be undisturbed, after which des- 
quamation ensues from a reddened, non-discharging surface. The 
cuticle about the lesions may be sodden, and macerated, or reddened ; 
it is usually painful and swollen. There is often produced a sensa- 
tion of pricking, burning, or itching. The eruption is most com- 
monly discovered upon the hands, and less frequently upon the feet; 
though other portions of the body may be involved. 

No little controversy has arisen respecting the exact nature of this 
disease, Fox and Crocker, on the one hand, 1 claiming a sudoral 
origin for the malady ; while Robinson 2 concludes, from a careful 
study of a single case, that " everything points against its being an 
affection of the sweat-glands." In his treatise this author names the 
disorder pompholyx, classes it where it properly belongs among the 
exudative affections of the skin, and describes it as a neurosis. The 
evidence on this point is striking. Fox says : " I never knew any 
patient who had this disease .... well. 7 ' He describes a 
condition of well-marked cachexia in all his cases. Robinson's 
patient was sickly for years, had twice suffered from fracture of the 
femur, had lost three, of six children, and was " depressed." The 
severest lesions exhibited by patients observed by the author, were 
those in a woman who had chronic enlargement of the spleen ; and 
in a man who was profoundly cachectic, suffered from night sweats, 
had a sallow hue of the skin, and subsequently died paraplegic. 

Geber, however, in studying two cases of this kind in middle-aged 
men coming under his observation, believed that the lesions were not 
pemphigoid. 

(For further details in connection with this subject the chapter on 
Pompholyx may be consulted.) 

H^ematidkosis, or bloody sweat, reported as observed by several 
authors (Foot, Ebers, Parrot), is a name applied to conditions in 
which blood has been seen to exude from an unbroken skin. The 
phenomena described under this title belong properly to the en- 
semble of symptoms called hsemophilia, and may in some cases be 
due to direct transudation of red and white blood-corpuscles and 
fibrin into the inter-epithelial spaces traversed by the sweat-pores. 

1 The Histology of Dysidrosis, London, 1878, from Trans, of the Path. Soc. of London, vol. 
xxix., 1878. 

2 Pompholyx, Arch, of Derm., 1877, vol. hi. No. 4, p. 289. 



SEBORRHEA. 113 

Geber points to the neuralgic, hyperaesthetic, pruritic, or emotional 
symptoms that are usual precursors to the flow of pale or bright red 
blood. The fact that the patients thus affected are mostly women, 
hysterical, dysmenorrhoeic, or near the puberal epoch, also throws 
light upon these cases. In many of them petechias, or signs of 
haemorrhage into other tissues of the body, are observed. 

In the effort to eliminate certain substances, accidentally or other- 
wise introduced into the system, the sweat may possibly become 
charged with iodine, turpentine, tar, arsenic, and other articles. 
Several of the eruptions described in the chapter on dermatitis 
medicamentosa are due to a similar eliminative effort, especially those 
accompanied by excessive sweating and the production of vesiculation. 

With equal reason it may be inferred that the sweat is at times 
charged with excrementitious and other products of the body ; as, 
for example, the principles of the bile. During the late civil war 
the author observed several patients affected with yellow fever whose 
skins exhibited the characteristic hue of that disease, and whose 
sweat was similarly colored. The so-called " Galactidrosis," from 
supposed metastasis of milk, does not occur. Cases thus described 
have been instances of pathological sweat in the puerperal state. 



2. Of the Sebaceous Glands. 

The disorders named in this group all depend upon functional 
derangements of the sebaceous glands, whose office, it will be remem- 
bered, is the supply in part of the physiological unguent of the skin 
and hairs. What proportional part of this process is borne by the 
coil-glands, and what part by the sebaceous glands, it is difficult to 
determine. It should be remembered that the varieties of acne, 
which is a disorder of the sebaceous glands and their periglandular 
environment, are described in Class II., among the inflammations of 
the skin. 

Seborrhoea. 

Lat. sebum, tallow ; Gr. pea, to flow. 

(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Sebaceous 
Flux, Stearrhcea. Ger., Schmeerfluss ; Fr., Acne Sebacee.) 

Seborrhoea : Statistical frequency in America, 1.47 ; S. oleosa, 0.296 ; S. sicca, 0.319. 

Seborrhoea is a functional disorder of the sebaceous glands, exhibited in an 

abnormal condition of the secretion as it collects upon the surface of the skin. 

Symptoms. — Seborrhoea occurs in two forms, according to the con- 
dition of the excreted product. These are known as seborrhoea sicca 



114 DISEASES OF THE SKIN. 

and seborrhoea oleosa. The two forms are recognized clinically as of 
separate occurrence ; and also as existing occasionally at the same 
time in one person. Either form of the disease may be limited to 
certain sites of preference, or be generalized so as to extend over all 
portions of the body provided with sebaceous glands. The most 
common seats of the disease are : the scalp, the face, the genital 
region, the dorsum of the bod}; between the scapulae, and the anterior 
surface of the chest. It appears at all periods of life, and in both 
sexes. As the sebaceous glands are mainly appendages of the hair- 
follicles, the lesions of the disease differ somewhat, according as they 
occur in the regions covered with long or lanugo hairs. In the same 
proportion, a difference exists in the career of the disease. At times 
it is a trivial and short-lived affection ; at others it is persistent and 
intractable, lasting for years, and possibly for a lifetime. The indi- 
viduals thus affected exhibit a difference also with respect to the 
general condition of their health. Some are anaemic, chlorotic, or 
asthenic ; some are of the sanguine temperament, fleshy, red-faced, 
and thick-skinned ; others again are absolutely healthy, so far as 
can be discovered, except for the local sebaceous disorder. This last 
fact is one of some significance. One may see exaggerated types of 
seborrhoea in vigorous men who have worn for one month merely, a 
skullcap, to which was fastened an apparatus for relief of fracture of 
the lower jaw. 

The skin affected with a seborrhoea is usually anaemic, and either 
dry or humid. In such cases the subjective sensations are either 
slight and limited to a moderate degree of itching, of which the 
patient does not complain until he is questioned upon the subject, or 
altogether wanting. At other times the glands, or periglandular 
tissues, are affected with a mild form of inflammation, and then the 
involved surface may be reddened and become the seat of a consider- 
able pruritus. 

Seborrhoea Sicca (or Squamosa). 

is the most common of all forms of the disease, and occurs upon 
both the hairy and non-hairy portions of the integument. In the 
former situation, where it is vulgarly known as " dandruff," it is 
called — 

Sebokrhcea Capillitii, in consequence of its limitation to the 
hairy scalp. In its ordinary manifestations, the affection is recog- 
nized in the adult, by the formation in this region, of greasy, whitish 
or yellowish pellicles of dried sebaceous matter, which may be freely 
shed from the surface and cover the shoulders of the individual whose 
scalp is involved. At other times these fatty plates are more or less 
adherent to the scalp surface, or piled up in laminae, one upon 
another. These may closely mat the hairs together, perceptibly near 
the exit of the latter from their follicles ; or be abundantly dissemi- 
nated through the mass of the hair, some of which penetrate a 



SEBORRHCEA. 115 

flattened greasy scale, as a twig might be passed through the centre 
of a leaf. In consequence of their deprivation of unguent, the hairs 
to which the affected glands are accessory, become dry and lustreless, 
and fall from their follicles. If the process be not arrested, atrophy 
of the hair-follicle ensues, and the resulting alopecia is permanent. 

Fortunately, the seborrhoea is usually symmetrical, and, corre- 
spondingly, the baldness which it occasions. The disfigurement then 
resulting is of the character of symmetrical senile alopecia, and is 
chiefly annoying as the loss of hair is premature. When the loss is 
asymmetrical, which is decidedly the exception, the disfigurement is 
greater. 

The affection may be circumscribed, and in conspicuously selected 
patches where thin, mealy, grayish, or whitish scales cover the patch : 
or thick yellowish masses may paste the hairs firmly to the surface 
of the scalp. The disease may also extend over the entire surface of 
the scalp uniformly ; or, as is frequently noticed, fringe the brow at 
the line of the hairs, and then extend chiefly over the vertex, being 
conspicuous at the line where the hairs are parted from vertex to 
brow. 

Beneath the scales or crusts of dried sebum the scalp is usually 
lustreless and of a slate-gray color. As the disease does certainly 
occur at times in types intermediate between functional and inflam- 
matory forms, the adjacent tissues may present a hypersemic or even 
exudative feature, with true epithelial desquamation and considerable 
itching — alopecia pityrodes, pityriasis simplex. One group of cases, 
assignable to this class, deserves attention. In them there is a tole- 
rably well- diffused seborrhoea sicca of the scalp, and, here and there, 
irregularly distributed over the surface, are filbert-sized, generally 
circular, dark reddish patches, covered with a moist secretion or a 
friable, granular, reddish and yellowish crust. These are scalp ex- 
coriations produced by the finger-nail. They are most common in 
" nervous " patients, who cannot resist forcibly digging the scalp on 
slight provocation. 

Occurring in infancy, the disease is well known as " milk crust/' 
or as Crusta Lactea. This may be merely persistence of the dried 
vernix caseosa about the vertex in the newly born, or it may occur 
in scalps which have been perfectly cleansed after birth. The crust 
differs somewhat in color with the tint of the child's complexion ; 
and may vary from a light yellow to a dark brown. It may be 
thick, greasy, and mat the hairs together; or be thin, dry, and 
friable. It is a frequent complication of the eczematous disorders 
of this region, and, as a consequence, more often in the adult, every 
variety of hypersemia and inflammation may affect the tissue beneath 
the crust. In infants and children, however, the resulting alopecia 
is never permanent, as the rapidly growing follicles hasten to repro- 
duce the hair. The disease is also neither contagious nor followed 
by cicatrices, points upon which mothers are usually solicitous. 

The regions of the brow, the surface covered by the beard of the 
male, and the pubic hairs may be involved in the disease. 



116 DISEASES OF THE SKIN. 

Seborrhoea of the non-hairy portions of the body may exist npou 
the face (forehead, cheeks, chin, and nose), trunk, and genitals. 

Seborrhcea Faciei is characterized chiefly by the accumulation 
of thick, dirty-yellowish, and even yellowish-black, accumulations 
of sebaceous matter, often adherent to the surface and disfiguring 
the features by the artificial mask produced. This is exceedingly 
conspicuous about the nose, where the disease is at times symmetri- 
cally disposed. There was lately exhibited to the medical class at 
the author's clinic, a young woman with a complete cast, covering 
the nose uniformly from root to alee, composed of only yellowish- 
gray sebum. Such masses once removed, the skin beneath is gen- 
erally found to be pallid or slightly reddened, with the orifices of 
the sebaceous ducts patulous ; while the under surface of the sepa- 
rated crust is seen to project downward in corresponding delicate 
prolongations, which Kaposi compares to stalactites. The crusts are 
rapidly re-formed when the disease is not arrested. They are found 
in the furrows on either side of the nostrils, on the brows, the cheeks, 
and the pavilion of the pinna of the ear. They are most common 
at the puberal epoch in both sexes, when the sebaceous glands of the 
skin undoubtedly sympathize with the changes occurring in the 
beginning of the sexual life. 

Seborrhcea Trtjnci is chiefly seen about the clavicles, scapulae, 
sternum, and umbilicus. Its features are less pronounced than those 
of some other localities, probably because the friction by the cloth- 
ing even in persons who neglect the care of their skins, serves to 
stimulate to a moderate degree the sebaceous glands of these regions. 
The disease occurs here in circumscribed or, more frequently, illy 
defined patches which by confluence may describe irregularly reticu- 
lated figures of reddish tint, when, as is usually the case, the few 
loosened fatty plates have been removed by friction. The chest 
patches are circular, pale reddish in color, defined in outline, separate 
or associated in large groups, and covered with withered, greasy, 
grayish-yellow pellicles, the eruption here much resembling ring- 
worm of the body. It is decidedly best exhibited over the sternum 
in men with the anterior superior surface of the trunk well covered 
with a pilary growth. About the umbilicus, the fatty matters are 
remarkable for their tendency to speedy decomposition, with the 
production of an exceedingly fetid odor, which may prove to be the 
source of a mild grade of inflammation. In the latter event, a red- 
dish halo surrounds the umbilical depression, which may be the 
source of a thin, sero-purulent discharge. 

Seborrhcea Genitalitjm is usually located in men in the sulcus 
behind the corona glandis, though in individuals with a tight or 
redundant prepuce it may be more extended. In women, the accu- 
mulation occurs about the clitoris and vestibulum, though the ex- 
ternal labia may be covered with the secretion in various degrees of 



SEBORRHCEA. 117 

fluidity. The smegma prreputii supplied by the glands of Tyson may 
be thus the source of trouble either by its retention, or secretion in 
abnormal quantity or quality. In either event the tendency, as in 
umbilical seborrhoea, is to decomposition, fetid odor, and subsequent 
irritation, which may provoke inflammation of severe grade. The 
retention of this smegma beneath a tight or redundant prepuce in the 
male may provoke a long list of reflex symptoms, such as inco-ordi- 
nation of movements in the lower extremities, nocturnal enuresis and 
pollutions, hernia, and irritability of the testis. In some cases the 
secretion forms a ring as hard as the rind of cheese encircling the 
glans. It should be remembered that the young of both sexes as 
well as adults are liable to be thus affected ; and that in young female 
children these symptoms may have a medico-legal interest in connec- 
tion with suspicion of criminal attempts. 

Seborrhoea Generalis affecting the entire surface of the body, 
is an exceedingly rare disorder. It has been described by authors as 
Ichthyosis Sebacea, Cutis Testacea, and Pityriasis Tabescentium. 
In the infant, the skin is universally spread with a greasy layer, 
rapidly renewed after removal, beneath which the skin seems to be 
varnished in reddish-brown shades. The consequent stiffening of 
the integument produces painful fissures, inability to take the nipple, 
and consequent marasmus. In adults, there is noticed the same 
marasmus ; with greenish to blackish crusts covering the trunk and 
extremities, and desquamation of lamella? of the sebaceous accumu- 
lation, corresponding, for the most part, to regions of the skin 
mapped out by its normal furrows and folds. 



Seborrhoea Oleosa. 

is in its pronounced features rarer than seborrhoea sicca ; but to a 
less distinct degree is a condition sufficiently common in many forms 
of the disease. Here the sebaceous secretion is poured out as an oily 
fluid upon the surface both of the hairy and so-called non-hairy 
parts of the skin. In the former situation, both in adults and 
infants, the free oily substance is seen to cover as a coating both skin 
and hairs, and, especially in bald adults, to produce a glistening and 
shining appearance of the scalp. It often concretes into masses 
which are described above as the crusts of seborrhoea sicca. The 
same greasy layer can be seen in the non-hairy portions of the skin, 
especially about the nose, forehead, and cheeks. Free drops of oil 
can be occasionally wiped from such surfaces with a handkerchief. 
The ducts of the sebaceous follicles are here either patulous or 
plugged with comedones ; the surface may be reddened or pallid, but 
is usually cold to the touch. The oily substance serves to entrap 
particles of dust, soot, etc., floating in the air, and often thus a 
peculiarly dirty or even blackish hue of the face is produced. Some 
of the forms of seborrhoea described above in connection with the 



118 DISEASES OF THE SKIN. 

umbilicus and genitalia, are of this variety. In the negro, where 
the sebaceous glands are usually well developed and active, the oily 
forms of seborrhoea are common ; and the flux, at times, almost 
physiological. Even in the absence of their frequent anointing with 
palm-oil, one can see the naked blacks in Africa with exposed skins 
shining from exuded grease. 



Seborrhoea Congestiva 

is a name given originally by Hebra, to one of the clinical portraits 
of early lupus erythematosus. In it the excretory ducts of the 
sebaceous glands, of the face more particularly, exhibit a plugging 
of the orifices with the exceedingly tenacious scales characteristic of 
this form of lupus. 

Eczema Seborrhoicum 

is a title given by Unna to a tolerably distinct clinical picture in 
which the symptoms of eczema and seborrhoea are distinguishable 
upon one surface. It is seen spreading from the scalp, axillary re- 
gions, and other regions of the body, often with a defined outline, 
the affected skin being covered with a greasy crust, yet exhibiting 
also the symptoms of eczema in the infiltration of the integument, 
the itching experienced, and the catarrhal discharge from the surface. 
This symptom of greasy sweating has suggested to Piffard the title, 
" Sudolorrhoea," and to Brocq the term t: oily hyperidrosis." This 
condition is more fully described in the chapter devoted to eczema. 

Etiology. — Seborrhoea may be due to local or general causes. This 
is a point which should be clearly understood, as Hebra, with his 
superb powers of observation, noticed that the majority of his cases 
occurred in young male and female subjects affected with chlorosis or 
conditions analogous to that state. It is a clinical fact of ready veri- 
fication ; but it is clear that many cases are essentially of local origin ; 
and, as before indicated, a seborrhoea can be artificially produced in 
a healthy individual in the course of a few weeks by very simple 
local measures without interference with the general economy. 
Women with long hair are usually disposed to take special care of 
the scalp, upon which it grows. Men with short hair are more apt 
to attend chiefly to its disposition upon the head, and to neglect the 
care of the scalp. For the seborrhoea sicca of the hairy parts, neglect 
of the scalp is a frequent cause ; for the same disease of the non-hairy 
portions of the skin, in by far the greater number of all cases, chlo- 
rosis, struma, malnutrition, obstinate constipation, disorders of diges- 
tion and menstruation, and sedentary habits of life, are unquestion- 
ably responsible. The exanthematous and other fevers are often 
followed by asthenic states in which the same condition prevails. 
Hebra pointed out the fact that the sebum of individuals who 
have fatty livers from chronic alcoholism, is peculiarly fluid and 



SEBORRHEA. 119 

oily ; and it will be observed that few of all the disorders of the 
sebaceous glands characterized by inspissation of the secretion occur 
in such persons. 

Among the indirect causes of this, as also of several other diseases 
of the sebaceous glands, may be named : the excessive use of tobacco ; 
the wearing of stiff, heavy, and ill- ventilated hats ; chronic alcohol- 
ism, gout, and syphilis. 

Of the several micro-organisms claimed to bear an etiological rela- 
tion to these several forms of disease, none has as yet been demon- 
strated to be effective. 

Pathology. — It will be remembered that the sebaceous secretion is 
produced in consequence of a fatty transformation of the epithelia 
lining the acini of the sebaceous glands ; it is, therefore, directly de- 
rived from the living matter of the protoplasmic elements of the rete. 
A seborrhcea is, therefore, strictly speaking, a catarrh of the epi- 
dermis ; and the name is in this connection properly used, since most 
of the so-called catarrhs of the skin are in reality not such, the effused 
fluids being furnished by the bloodvessels. Typical forms of sebor- 
rhcea are strictly anomalies of secretion only, unaccompanied by in- 
flammatory processes in either the glands or periglandular tissues. 
While other exceptional forms are without question thus complicated, 
the variations in the sebaceous product as to quantity, iuspissation, 
fluidity, tendency to rapid decomposition and exhalation of fetid 
odors, may be due to variability in the transformation of the epithelia 
into fat under the influence of the trophic nerves, but this is a matter 
of conjecture. It is certain that these conditions are largely under 
the influence of external agents, such as friction, temperature, and air 
currents. In many cases the product of the disorder is composed, for 
the greater part, of epithelial masses mingled with a relatively small 
quantity of sebum, thus justifying further the view explained above 
regarding its catarrhal nature. 

The unguents naturally found in excess upon the body or parts of 
it, such as the vernix caseosa, are, of course, physiological in character. 

Diagnosis. — Seborrhcea is to be distinguished from : 

Eczema. — The objective points of difference between eczema and 
seborrhcea depend upon the inflammatory character of the first named 
disease, easily recognized, whether upon the face or scalp ; by the red- 
dened, infiltrated, or discharging skin ; and by the considerable degree 
of itching which it occasions. In squamous eczema, the scales are 
rarely so abundant as to be shed freely from the surface, and are not 
greasy. It should be remembered, however, that the two diseases 
may and do coexist. Eczema of the scalp in infants is especially apt 
to be accompanied by a seborrhcea, a fact which clearly shows that the 
technical distinctions between many diseases, useful though they be 
for analytical study, are not always capable of clinical demonstration. 

Ichthyosis. — This is a congenital disease, usually involving the 
entire surface of the body, while seborrhcea is generally acquired, 



120 DISEASES OF THE SKIN. 

and rarely universal. The distinction between ichthyosis and the 
rare generalized forms of seborrhoea, described above, might involve 
a difficulty. But in the latter, the greasy character of the crusts, 
their color, and the marasmic condition of the subject of the disease, 
would sufficiently distinguish the two disorders. 

Impetigo and Impetigo Contagiosa. — Here the only possibility 
of error would originate in the discovery of either of the two diseases 
named, in the stage of crusting, especially upon the scalp. But both 
are acute disorders, with crusts much bulkier than the sebaceous 
matters formed in seborrhoea, and beneath such crusts the integument 
is reddened and evidently the seat of an exudation. 

Keratosis Pilaris. — In this disease, also, there is a chronic 
accumulation of matters, partly sebaceous, on the hairy and non-hairy 
portions of the skin. But, unlike seborrhoea, the sebo-epithelial 
heaps are here aggregated in pin-head sized masses about the hair- 
follicles only, and never accumulate in such quantities as to paste 
the hairs to the surface. The disease is also most common on the 
extensor surfaces of the extremities. 

Lupus Erythematosus — Hebra, in 1845, described a Seborrhoea 
Congestiva, which it would be indeed difficult to distinguish from 
lupus erythematosus, as the two are practically identical. Typical 
cases of the two diseases are widely different and readily distinguished ; 
the atypical forms might lead to confusion. But lupus erythematosus, 
though occurring on the face, is rare on the scalp ; it is accompanied 
by infiltration and the production of a new growth ; and is followed 
by a characteristic scar. Its lesions are darker red than the conges- 
tive patches beneath certain seborrhoeas of the non-hairy parts. The 
scales of lupus are tenacious and dry, and require scraping for 
their removal ; those of seborrhoea are readily detached, greasy, aud 
often cover the shoulders of the patient. The contour of the sebor- 
rhceic patch is ill defined, while that of lupus is very distinct, excep- 
tion being made of the mask-like crusts seen in certain of the facial 
seborrhoeas, when the greasy character of the layer is very evident. 
Lastly, seborrhoea is a disease of puberty chiefly, while lupus erythe- 
matosus may be first seen in childhood, when facial seborrhoea is 
rare. 

Psoriasis. — Psoriasis of the scalp may resemble seborrhoea sicca. 
But the latter is rarely developed in such a universal exanthem as is 
frequent in the former. Few doubtful cases will come under obser- 
vation, in which a psoriasic patch on the elbow, knee, leg, or sacrum, 
will not point to the nature of the disease. The scales of psoriasis 
are lustrous, larger, and not greasy, unless fatty applications have 
been made to soften them ; and they cover, moreover, a reddened and 
exuding patch of integument. Psoriasis of the scalp and face prefers 
the areas of the forehead adjacent to the hairs of the scalp, and rarely 



SEBORRHEA. 121 

departs boldly to the nose and the furrows beside the nostrils, favorite 
sites of a seborrhoea. 

Syphilis. — Some forms of the pustular syphilodermata located 
upon the scalp and face, if observed only in the stage of crusting, 
might be confounded with seborrhoea. Here the history of the case, 
the discovery of other signs of syphilis (adenopathy, mucous patches, 
etc.), and the puriform character of the secretion beneath the crust, 
should point to the identity of the disease. In syphilitic crusts about 
the angles of the nostrils there is often a peculiar reddish-brown tint 
of the skin at the edge of the patch, the so-called " copper" color, 
which is significant. Crusts of the hairy scalp in syphilis are very 
often accompanied by post-cervical adenopathy, and especially by in- 
durated enlargement of the occipital glands. 

Tinea Circinata and Tinea Tonsurans. — In ringworm of 
the hairy parts, as also of the body, the microscopical discovery of 
the parasite will always point to the nature of the disease. Upon 
the scalp, the affected patches are seldom as diffuse as in seborrhoea ; 
are usually circular ; are often accompauied by fragility of the hairs ; 
and, in the latter case, the discovery of stumps of hairs is significant. 
There is also a history of coutagion aud absence of the greasy condi- 
tions of the scales characteristic of seborrhoea. 

Treatment — The geueral and internal treatment of seborrhoea is 
of the highest importance. The preparations most often indicated 
are : Iron in anaemic young women ; cathartics in sluggishness of 
the bowels ; and cod-liver oil when there is impairment of nutri- 
tion. Duhring recommends the sulphide of calcium in doses of from 
one-tenth (0.0066) to one-fifth (0.0133) of a grain. Arsenic, em- 
ployed in the manner suggested by Sir Erasmus Wilson, is praised 
bv Hebra : 

R. Vin. ferri fSJss; 50 

Syrup, simpl. j Aafzii; 8 

Liq. potass, arsenit. J ° J ' 

Aq. destill. fgij; 60 M. 

S. A teaspoonful to be taken three times daily with the meal. 

In many cases, the acid iron mixture of Startin, or some modifi- 
cation of it, admirably meets the indications present : 

K . Magnes. sulph. % ij ; 64 

Ferri sulphat. 3}ss-£j; 0.66-133 

Acid, sulph. dilut. f^ij-f %iv ; 8-16 

Infus. quassia? adfjfiv; 128 ! M. 

S. A teaspoonful in water, through a tube, after eating. 

The preparations of matzool, malt, and maltine, now largely employed 
in the treatment of wasting diseases, will be found available in cases 
where cod-liver oil cannot be well taken. Lastly, the bitter tonics may 
be needed. Throughout the treatment, the physician should insure 



122 DISEASES OF THE SKIN. 

a careful observance of the laws of hygiene. Sunlight, nutritious 
food, and open-air exercise are not to be disregarded. In the large 
cities of this country, many young women of indolent habits are 
greatly benefited by sending them to the riding-schools for an hour's 
equitation daily. 

The author is in the habit of ordering, in cases where it can be 
tolerated, daily cool salt and water sponging of the entire bodily 
surface, followed by brisk friction. The salt is added to the water in 
the strength of one-quarter of a pound to the gallon. There is no 
advantage to be gained by using the preparations of " sea salt " sold 
in the shops. The bath is omitted during the menstrual period in 
women, and in the case of all delicate patients. It is, without ques- 
tion, the most valuable of all hygienic measures in the management 
of the disease. 

The indications to be met by local treatment in seborrhoea are : 
first, the removal of the crusts and the fatty matters accumulated 
upon the surface ; second, the restoration of the deranged function of 
the glands. 

Upon the scalp, it is always well to warn patients, especially if the 
disorder be aggravated, and occur in young women with apparently 
luxuriant tresses, that a considerable loss of hair will result. Many of 
the filaments are so impoverished by the chronic course of the disease 
and so loosened in their follicles, that a complete cleansing of the 
scalp surface will bring them away in quantities sufficient to threaten 
a speedy baldness ; and it is not rarely the case that patients attribute 
this to the treatment rather than to the disease. The fatty accumu- 
lations are first to be soaked in some oily fluid to facilitate their 
removal ; and for this purpose olive oil, cod-liver oil, vaseline, cold 
cream, almond oil, glycerin, or lard is usually employed. The 
article selected should be used in excess, and in quantity sufficient to 
permeate all crusts. It may be poured over or rubbed into the scalp 
several times in the twenty-four hours ; and at night a flannel or 
other cap be worn to insure still further success. In the case of 
children and infants, considerable gentleness is required in thus 
treating the scalp, especially in the subsequent washings, lest the 
surface be irritated. In young women it is rarely necessary to cut 
the hairs. As soon as the soaking with oil is insured, the crusts are 
to be removed by washing with soap and water, though when the 
accumulations are bulky, masses may be gently removed with fingers 
or comb. When the scalp is quite tender, ordinary toilet, or Sarg's 
glycerin soap, may be applied with warm water ; but it is usual, in 
the case of adults, to employ the spiritus saponis kalinus of Hebra, 
two parts of green soap digested in one of alcohol, filtered and 
flavored with lavender or bergamot. The surface should be thor- 
oughly sponged with spirit, and then warm water added till the foam 
of the lather is abundantly produced over the scalp, when an excess 
of water is finally used to cleanse the part of both crusts, oil, and 
soap. The scalp and hairs are then thoroughly dried, and anointed 



SEBORRHCEA. 123 

with some bland, fatty substance, if the surface exposed be tender 
and irritable; if not, with some stimulating pomade. 

The last-named precaution is an important one. However exten- 
sive the seborrheic crusts, it is possible to remove these completely 
by the measures described above, in every case; and with the first 
experiment patients are often delighted. Their disappointment is 
correspondingly great when they discover that the seborrhoea is not 
yet at end, and that, in the course of a few days, the fatty plates are 
as freely as ever deposited on the scalp, disseminated through the 
hairs, and showered upon the shoulders. Some will even declare 
that the soapy applications aggravate the disorder by increasing the 
seborrhoea. It should, therefore, never be forgotten that, having got 
rid of the extraneous matters accumulated upon the surface, there is 
still to be remedied a functional disorder of the sebaceous glands of 
the part. 

In every case, then, after the use of the soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, or 
once in the week, the scalp is to be thoroughly anointed. For this 
purpose olive oil, cod-liver oil properly scented, almond oil, vaseline, 
or glycerin and water may be used. In most instances, a more 
stimulating plan of treatment may be adopted in the course of a few 
days ; and, in that event, alcohol may be combined, for example, 
with the oil of sweet almonds, half an ounce (16.) of the latter to five 
ounces (160.) of the former, to which half a drachm (2.) of carbolic 
acid may be added, the whole flavored with the oil of bergamot. 

Van Harlingen recommends the oleum sesami, or oil of benne, 
as a substitute for others, since it does not dry and clog, as do the 
latter. An ounce (32.) of this rubbed up with five grains (0.33) of 
powdered benzoin, and digested for three hours over a water-bath, 
with the addition of three drops of absolute alcohol, and filtered, 
furnishes an excellent basis for oily mixtures to be used on the scalp. 

Dr. Morrison, 1 of Baltimore, has devised an ingenious instrument 
for the application of oily fluids to the scalp. The latter are retained 
in a small reservoir, to which is connected a comb with perforated 
teeth. Through the latter the article selected for medication of the 
scalp readily passes down to the surface between the hairs. 

In the place of oils after these ablutions the ointments are often 
used with more advantage. For this purpose the benzoated oxide of 
zinc ointment, cold cream, or salves containing ten per cent, of tannin 
may be applied. 

In cases where milder effects are required, the scalp may be washed 
in water containing such alkaline substances as borax, ammonia, and 
the carbonate of potassium. The popular prejudice against these 
articles is based upon the abuse of strong alkaline lotions in the 
hands of inexperienced persons. Such lotions may be readily tested 
by the tongue for the degree of softness required for the scalp. 
They should, in the management of all cases, be followed by an oiling 

1 Maryland Med. Journ., January, 1885. 



124 DISEASES OF THE SKIN. 

or greasing of the surface. Women solicitous about their personal 
appearance are apt to object to such inunctions, preferring greatly the 
drier conditions of the scalp and hair, a prejudice often responsible 
for the disease in question. 

Veiel recommends the following formula : 

R. 



Extr. cinch, frig. par. 


Bj; 


1 


Bals. peru v. 


gtts. xv ; 


i 


Cantharid. tinct. 


gtts. xxiv- 3 ss ; 


1.5-2 


Succ. citri 


m*v; 


1 


Ungt pomat 


Ijss; 


50 



M. 

S. To be rubbed into the scalp once or twice daily. 

The tars are useful in many obstinate cases. Tar soap may be 
employed in the washing ; or the oleum rusci added in the strength 
of one to ten parts to the other salves recommended above. Ichthyol 
in ointments of the strength of five to ten per cent., and resorcin in 
spirit lotions of ten grains (0.66) to the ounce (32.) have also proved 
efficacious. 

Repeated applications and patient care of the scalp are necessary to 
secure complete relief in the case of a disease as essentially chronic 
as seborrhoea. At times the local treatment may be changed with 
advantage. Sulphur enjoys a high reputation in the treatment of all 
sebaceous gland disorders ; and in the form of an ointment, one to 
two drachms (4.-8.) to the ounce (32.) of cold cream, it is often of 
service. It may also be used as a powder, either alone or in combi- 
nation with talc, salicylic acid, boric acid, starch, or camphor ; and as 
a lotion with alcohol, glycerin, and rose- or cologne-water. The 
author has used with success the hydrochloride of sulphur, which has 
lately come into our markets from the English laboratories. But it is 
open to objection on account of its odor, which can scarcely be dis- 
guised. Beside these, the tinctures of cantharides, capsicum, and 
mix vomica are frequently incorporated with advantage into lotions 
and pomades for use upon the scalp. Most of the latter can be made 
sufficiently fluent for use in this situation, by adding a drachm (4.) or 
two (8.) of glycerin to the ounce (32.) of lard or cold cream. The 
alterative effect of the mercurials is also as evident here as in many 
other cutaneous disorders. At the head of the list, for this special 
purpose, stands the red oxide of mercury in the strength of from two 
to four grains (0.133-0.266) to the ounce (32.) of ointment ; but the 
white precipitate, the ammoniated mercury, and calomel, in the pro- 
portion of five to ten grains (0.333-0.666) to the ounce (32.) may be 
often substituted for the former with advautage. Solutions of cor- 
rosive sublimate, in the strength of two to four grains (0.133-0.266) 
to the ounce (32.) of fluid, may prove of use in obstinate cases. Hil- 
lairet recommends a lotion containing from two to four fluidrachms 
(8.-16.) of sulphuric ether and two to four drachms (8.-16.) of borax 
dissolved in eight fluidounces (256.) of distilled water. 

Yiguier advises the following lotion for use in seborrhoea of the 
scalp, in those cases more particularly where loss of hair is threatened : 



SEBORRHCEA. 125 



R. — Santal. ess. 
Eosar. ess 
Chimaphil. unibell 
Pilocarpi?!, muriat. 
Spts. vin. rectif. 


ess. J 




ft&TKlv; 

gr. vijss ; 


30 

50 
100 




Camphor, spts. 1 
Glycerin. >- 
Cantharid. tinct. J 
Dissolve the pilocarpine in 
dients. 


aa 3j gr. xv ; 5 

the alcohol, and then add the 


other ingre- 



The treatment described above in outline may be used with 
success also for the relief of seborrhoea of the non-hairy portions of 
the body, especially the face. Here, it will be observed, the crusts 
have a singular tendency to re-form, and the most persistent care is 
necessary to secure permanent relief. Occasionally, after cleansing 
the surface by soap and spirit lotions, according to the indications of 
each case, it is of advantage to apply the ointment selected for subse- 
quent application, not only by gently smearing it on the part with 
the tips of the fingers (always the most effective method), but also by 
spreading it on a compress, which, for the night at least, may be 
fixed in contact with the part. 

Unna's lead-plaster mulls, used for this purpose in Germany, may 
be fairly well imitated by drawing strips of cheese-cloth through 
heated diachylon ointment and then smoothly smearing them with 
the same material. 

When this tendency to reformation of the crust is abated, one or 
more of the dusting powders may be at times employed with advan- 
tage for the purpose of protecting the skin or exercising upon it an 
astringent effect. 

The local treatment of seborrhcea of the genitals is somewhat 
different. Ointments rarely answer well in disorders of the mucous 
surfaces ; and the green soap is too irritating for similar employment. 
Here washing with a good toilet soap and warm water is sufficient 
for the purposes of cleanliness, and diluted lotions containing alcohol, 
in the form of whiskey, brandy, or aromatic wine, suffice to procure 
relief. These can be made astringent with tannin, alum, or the zinc 
sulphate, and, when there is pain or tenderness, opium can be added. 
In this form of the disease, as also in seborrhcea of the umbilicus, 
carbolic acid or the chlorinated soda may be necessary to correct 
fetor. After the employment of these lotions, boric acid, with talc (one 
part to four) or zinc oxide and starch (one to eight), may be dusted 
over the part. In the generalized varieties of the disease the surface 
is to be thoroughly anointed with oil. The body, especially that of 
infants, is to be swathed in flannel or other good non-conductor of 
heat ; and a roborant treatment directed to the general adynamia. 

In the grave forms of seborrhcea of infants described as keratosis 
sebacea, ichthyosis sebacea, etc , the body must be kept anointed with 
oils or fats. Artificial feeding is demanded by the condition of the 
mouth. 

Prognosis. — In forming a prognosis in cases of seborrhcea, it must 
be remembered that the disease is frequently an obstinate one ; and 



126 DISEASES OF THE SKIN. 

the resulting loss of hair, if symmetrical, may be remediless. Much 
may be done in the way of saving that which is left. Facial sebor- 
rhea is much more amenable to treatment; and seborrhea of the 
genitals and umbilicus is an entirely manageable disease. When 
the affection is generalized, the prognosis is in the highest degree un- 
favorable. 

Comedo. 

Lat. comedo, spendthrift. 

(Black-head. Gee., Mitesser; Fk., Acne' Ponctuee.) 

Statistical frequency in America, 0.989. 

Comedo is a disease in which an inspissated secretion, lodged in the excretory 
ducts of the sebaceous glands, becomes visible upon the surface in yellowish- 
white or brownish-black points. 

Symptoms. — Comedones occur exclusively in the ducts of the 
sebaceous glands, and consist of a whitish fatty plug formed by the 
inspissation of the secretion of these glands, one extremity of which 
is visible at the surface when the plug is in situ. Occasionally they 
project to an appreciable distance above the general level of the 
integument ; but often the extremity of the plug is slightly depressed 
below that level. There may be but two or three upon the face, 
which is their most common seat ; or the nose, forehead, cheeks, 
chin, the front and back of the neck, the back of the trunk, and the 
penis may be thickly studded with them. The visible extremity of 
the comedo varies in size from a needle-point to a pin-head. They 
are readily expressed from the follicles in which they are lodged, and 
when thus examined are seen to be whitish moulds of inspissated 
sebum, one or two lines in length, the exposed extremities of w T hich 
have become blackened by the dust and dirt entrapped at that point. 
In consequence of this suggestive appearance of the mass, the disease 
has been vulgarly known as a black-heads" and " skin worms." The 
deformity produced in the face when these lesions exist there in large 
numbers, is strikingly conspicuous; and it is for the relief of this 
chiefly, that the practitioner is consulted. The subjective symptoms 
awakened are of trifling moment. The disorder is essentially chronic 
in its course. Isolated comedones may be observed for years in one 
situation without apparent change or modification of any sort, and 
without producing the slightest local or constitutional derangement. 
Others appear, only to disappear under the influence of the usual 
hygienic regimen of the skin of the face. Others, again, serve to 
irritate the skin in which they are implanted, precisely as though 
they were foreign bodies ; and the sebaceous glands and peri-glandular 
tissues, with and without the operation of such cause, exhibit grades 
of hyperemia and inflammation. Comedones may occur as the sole 
lesions of the skin, even to the extent of very great multiplicity ; or 
they may coexist with other diseases of the glands, chiefly acne. They 
may occur at any period of life, but, like seborrhoea, are most fre- 



COMEDO. 



127 



quently observed at the puberal epoch in both sexes. According to 
Kaposi, the disease tends to disappear in women earlier than in men, 
in whose case it may be prolonged to the twentieth or thirtieth year. 
Crocker 1 has called attention to the occurrence of comedones in 
children, with a special tendency to grouping in places subjected to 
heat and moisture, and also to occurrence upon the hairy scalp. 

Fig. 35. 




Section of a comedo, a, excretory duct of a sebaceous gland filled with a comedo ; it 
contains also two small hairs with brush-like inferior extremities ; into it opens a small hair- 
follicle, c, whose contained hair, d, after touching the opposite wall of the duct, curves down- 
ward at/. (After Kaposi.) 

Occasionally a so-called " double" comedo is formed, a plug of 
inspissated sebum being expressed from the skin, each extremity of 
which is discolored. Whether this be due to a duplicity of efferent 
ducts in a single gland, or to an artificial or pathological connection 
between two adjacent glands, is not clear. 2 

Etiology. — Much has been written with reference to the improper 
care of the skin as a cause of comedo, the neglect of soap in washing 
the face, and the influence of the trades, as in the case of those who 
work in metals, dust, and tar. But observation shows that these are 
exceptional causes. Very obstinate and generalized lesions occur in 



Lancet, April 19, 1SS4. 

Ohmann-Dumesnil : Journ. of Cut. and Ven. Dis 



Feb., 1886. 



128 DISEASES OF THE SKIN. 

the skin of intelligent young men and women of the upper social 
classes, who regularly wash their faces with toilet soap, are rarely 
exposed to dust, and whose habits and recreations are of the most 
healthful character. On the other hand, observing the grimy faces 
of coal heavers, machinists, masons, and ink manufacturers, one is 
impressed with the singular rarity of the disease in such laborers. 
The cause of the constipation of the gland is unquestionably to be 
sought for elsewhere, in the most of cases. It is true that chlorotic 
young women, affected also with dyspepsia and torpor of the bowels, 
may exhibit the disease ; and equally certain that many cases occur 
in peculiarly thick-skinued brunettes, or men with a characteristic 
reddish-brown and greasy-looking complexion. But for all this, 
many such never suffer from comedones, while often a perfectly 
healthy, fair-skinned girl will be greatly mortified by the disfigure- 
ment of her face. 

In yet other patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of 
the bowels, menstrual derangements, and cachexia. This connection 
is demonstrated by the remarkable improvement manifested in the 
untreated skin when improvement of the general health is assured. 

Pathology. — The mass termed the comedo is a collection of con- 
centrically packed epithelial plates mingled with masses of choles- 
terine, fragments of epithelia undergone fatty transformation, minute 
lanugo hairs, and, occasionally, upon the exterior, the acarus follicu- 
lorum. This little mite, first detected by Henle, in the ceruminous 
glands, was by Simon and others once thought to be the cause of the 
comedo, a view which is now abandoned by all dermatologists. The 
parasite, in persons upon whose skin it exists, can be detected in 
masses of commingled sebum and epithelial plates scraped from the 
free surface of the integument, as also upon the surface of those 
who do not exhibit any disorder of the sebaceous glands. 

The comedo plug is located either in the excretory duct of the seba- 
ceous gland or in the pouch-shaped canal common to the sebaceous 
gland and the hair- follicle. It will be remembered that in the class 
of sebaceous glands chiefly involved in the comedo, the hair- follicle 
is rather an appendage to the former, the relation between the two, 
evident upon the scalp for example, being here reversed. According 
to Biesiadecki, the hair-follicle often forms here an obtuse or even a 
right angle with the duct of the gland, and the point of the hair 
being thus projected against the wall of the duct, is occasionally 
curved downward upon itself, exciting thus au irritation at the point 
of impact and subsequent multiplication of the protoplasmic elements 
lining the canal. Thus he explains the epithelial character of the 
outer envelope of the plug ; the special occurrence of the disease at the 
puberal epoch, when, as is well known, there is an especially active 
growth of the hairs ; and, lastly, the frequent discovery of lanugo 
filaments in the expressed contents of the common excretory duct. 

Diagnosis. — The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 



COMEDO. 129 

identify the affection, though frequently misled as to the character of 
the u skin worm." It is, as might be expected, a frequent coincident 
of acne ; its lesions, when commingled with those of the disease last 
named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
the comedo may be produced upon the face when tar, or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various points upon the 
skin, often at the orifices of the sebaceous glands. 

Curiously atypical cases, however, are occasionally observed, and 
these might confuse one unfamiliar with the singular variations dis- 
played in almost all sebaceous gland disorders. Thus Cauty 1 reports 
a remarkable case in a boy ten years of age, who was somewhat im- 
becile but well nourished. The upper part of the back, both shoulders, 
and the outside of both arms were covered with short bristles, of a 
clear, darkish brown-yellow color, and acuminated apices. These 
bristles were, at the edges of the group, gradually shortened from 
their full length of three thirty-seconds of an inch, until they joined 
the skin, which was at the junction raised into polygonal, flat disks, 
finally graduating to the sound integument of the hands, chest, and 
back. The feeling communicated to the hand on passing it over the 
shoulders was exactly similar to that of touching a coarse brush, and 
the bristles gave way under the touch, resuming an upright position 
afterward. There were a few pink maculae over the body, and con- 
siderable scaly thickening on and around the patellas. The bristles 
were expelled comedones, containing very few immature hairs and 
very little sebum, drying up into a horny substance. They were 
firmly attached, requiring more force to remove them than to extract 
a well-rooted hair ; and when removed they left a small, central 
depression, surrounded by a circle of torn epithelium, which retained 
them in position. They averaged oue hundred to the square inch, 
and had existed over three months. 

A somewhat similar case was exhibited by Dr. Warren, before the 
New York Dermatological Society, January 26, 1886, and described 
as keratosis follicularis. 

Treatment. — The internal treatment of the patient affected with 
comedo is largely that described in connection with the subject of 
seborrhcea. Cod-liver oil, iron, the bitter tonics, and preparations 
indicated by any special condition of the patient's health, are not to 
be omitted. Open-air exercise, daily cool salt-and -water bathing, as 
in the management of seborrhcea, and the avoidance of all medicinal 
and dietary articles which might tend to aggravate the disorder, are 
also imperative. 

Even aggravated cases of comedo are completely relieved by natural 
processes in the course of time. These processes are, however, slow, 
and may require years for their completion. The rarity of come- 
dones in middle life and advanced years sufficiently attests this fact. 

1 Medical and Surgical Journal, March 4, 18S2, p. 237. 



130 DISEASES OF THE SKIN. 

Presumably this natural cure is due to the more vigorous growth 
of lanugo hairs with the increment of age, which thus push forward 
slowly to the surface the excrementitious mass, until it is gradually 
removed by ordinary friction and ablution. Absence of comedones 
from the scalp, where the hair is vigorous, is certainly a significant 
fact. 

Comedones are removed artificially by the aid of an extractor. The 
instrument formerly employed for this purpose was shaped like a 
watch-key, the cylinder of which had a smooth bore and bevelled 
extremity. This clumsy tool is far surpassed by the exceedingly 
convenient comedo-extractor designed by Unna and modified by 
Piffard (see Fig. 33). Each end has a convex bowl-like surface, with 
apertures cut to gauge and the orifices slightly counter-sunk. It is 
productive of far less pain to the patient than other instruments, and 
can be wielded, on account of its long shank, with greater precision 
and ease by the physician. The surface to be operated upon is best pre- 
viously moistened by spraying it with a thymol and glycerin, or euca- 
lyptol and glycerin solution. Often a sharp-edged or well-rounded 
needle, firmly held in a needle-holder, may be advantageously em- 
ployed alternately with the extractor, in opening certain follicles or 
somewhat loosening the plug of others. All of these instruments 
should be scrupulously disinfected before use. With the present 
knowledge had on the subject of transmission of disease, the danger 
of such manipulations as these with uncleansed instruments should 
never be overlooked. Wigglesworth suggests the performance of 
the operation at night ; and there are good reasons for selecting the 
hour before retiring as the time for all vigorous topical applications 
to the face. Ointments then applied can be left in contact with the 
skin during the hours of sleep; and the patient be at liberty to 
resume his usual vocation in the daytime with his face free from con- 
spicuous evidence of local treatment. 

An ordinary watch-key, a curette, the thumb-nail, or a spatula 
may also, on occasion, be used in the extraction of comedones, which 
may be, if few, removed at one sitting, or, if numerous, on separate 
occasions. Repetition of the process is usually required by the re- 
formation of the plugs. 

Once they are removed, the skin should be sponged and bathed 
with hot water, then thoroughly dried, and anointed with an oint- 
ment which may be medicated to suit the indications of each case. 
Sulphur, as in all the functional disorders of the sebaceous glands, 
enjoys here also the highest reputation. In the strength of one-half 
to one drachm (2.-4.) to the ounce (32.) of cold cream or vaseline, it 
may be applied as an ointment ; or as a lotion, in combination with 
spirits of wine, glycerin, etc. The author has frequently used with 
advantage the mild application suggested by Piffard in acne, equal 
parts of sublimed sulphur, alcohol, compound tincture of lavender, 
glycerin, and camphor water. 

Mercurials are also of some advantage locally, and, as before indi- 
cated, should not be employed at the same time with preparations of 



COMEDO. 131 

sulphur. The use at night, especially in obstinate cases, of the white 
precipitate ointment, or one compounded of two grains (0.183) of the 
red oxide to the ounce (32.) of cold cream will often prove of benefit. 
One to two grains (0.066 to 0.133) of corrosive sublimate to the 
ounce (32.) of glycerin and rose-water may be substituted for the 
latter in coarser skins. 

When the extraction of the plug is not attempted nor permitted, 
something may yet be done to remove the inspissated mass. Ee- 
peated sponging every third night with one ounce (32.) of the green 
soap, digested in an equal quantity of Cologne water, will, at first 
certainly, seem to render the comedo more conspicuous, but will 
slowly operate to dissolve the sebaceous secretion. 

Unna has lately observed that the blackish discoloration of the 
comedo extends to a certain degree below the external extremity of 
the plug, a circumstance, in his opinion, militating against the dust 
and dirt theory, by which the hue of the comedo point has been ex- 
plained. He concludes that this is the result of pigmentation, such 
as that producing the coloration of the hair, nails, and skin in several 
other anomalous conditions. Having this in view, he prescribes an 
ointment containing four parts of kaolin, three of glycerin, and two 
of acetic acid, with or without the addition of a small quantity of 
ethereal oil. This is applied at night, the eyes being carefully closed, 
for a few nights in succession, when the black points of the lesions 
are removed, and the comedones then readily extracted. Citric or 
dilute hydrochloric acid is employed, with the same end in view. 
These topical remedies cannot be considered as efficient in every form 
of comedo. 

Actors, actresses, and women of fashion will occasionally persist in 
using variously colored toilet powders while under treatment, the 
injurious ingredients of which are often the cause of the disease. 
The practitioner may then either refuse to be responsible for the 
care of the case, substitute a harmless for a noxious powder, or 
gently anoint the face after his treatment of it with a bland oint- 
ment or the Lassar paste, upon the surface of which the theat- 
rical effects are subsequently produced. In such cases the use of 
soap and water with each dressing is even more than usually im- 
perative. 

Comedones of the penis need not be treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with a degree of 
alarm which he can best appreciate who has been confronted with 
these cases. 

Prognosis. — As the disease tends naturally to a spontaneous, though 
occasionally long-deferred resolution, the prognosis is favorable. 
Treatment in many cases will accomplish much in hastening the re- 
sult. The most obstinate forms are those in which the face, back of 
the ears, inside of the auricle, neck, and shoulders are studded with 
relatively small, indolent, comedo points, about which the orifice of 
the duct arises in a whitish rim. This, when felt with the finger, 



132 DISEASES OF THE SKIN. 

produces the impression of hyperplasia of the wall of the duct. Such 
cases, however, are nearly allied to the forms of acne described else- 
where. With exceeding rarity, the comedo is merely the first step 
of a more serious local affection. In early life a single prominent 
lesion is formed, and though the plug be frequently removed and 
finally be no longer reproduced, the orifice of the duct remains patu- 
lous in middle life. Slowly thereafter its walls undergo a metamor- 
phosis and a warty epithelioma may result. 

Cyst. 

Gr. Kvcrig, a bladder. 

Sebaceous cysts are millet-seed to egg-sized and larger, milky-whitish, or 
yellowisn-white, encysted tumors of the sebaceous glands, occasionally having 
the color externally of the normal integument, either imbedded within the 
skin or projecting above it. 

The term sebaceous cyst is applied by some authors to one merely 
of the two disorders of the skin to which it properly belongs, viz., 
the wen. In these pages it includes both milium and steatoma. 

[A.] Milium. 

Lat milium., a millet-seed- 

(Grutum, Strophulus albidus, Acne albida.) 

Symptoms. — Milia occur upon and about the eyelids, the cheeks, 
the temples ; the penis, scrotum, and corona glandis of men ; and 
the internal face of the labia minora of women. They are millet- 
seed to pin-head sized, globoid masses, rarely attaining the dimen- 
sions of a coffee-bean, showing within the epidermis as though 
kernels of rice were lying there immediately beneath a translucent 
layer of tissue. They occasionally project from the surface to such 
an extent as to resemble small-sized vesicles having milky con- 
tents. In color they are yellowish and whitish. They are often 
congenital, and can be recognized about the lids and temples of the 
newly born infant ; they are also seen, however, in middle life, 
when they develop very slowly, and sometimes persist for years. 
They are often observed in the neighborhood of cicatrices, which 
latter in such cases have usually been effective in their production. 
They occasion no subjective sensation, and are commonly so insignifi- 
cant as to induce no deformity. They never degenerate by ulcerative 
processes, but when not artificially removed are, in the course of 
years, exfoliated in the natural processes of physiological desqua- 
mation. 

Etiology, — Milia are at times produced mechanically, the stroke of 
a knife-blade, accidentally or by the processes of surgery, separating 
one or more of the acini of a sebaceous gland from the main body. 
The contracting bands of a cicatrix, after the destruction of tissue 



CYST. 133 

from any cause, may operate in a similar way with a precisely 
similar result. Haviug this in view, it may be said generally that 
milium is always the result of a cause which prevents the transform- 
ation of the epithelium lining the gland into fat, and the subsequent 
excretion of this upon the free surface of the skin. These causes are 
thus, for the most part, obscure, but all are probably of purely local 
significance. 

Pathology. — When a milium is incised externally, a spherical body 
of nearly corresponding size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attach- 
ment to the hair-follicle. The small mass thus extracted is theu 
seen to be composed of several thin envelopes suggesting the capsules 
of the onion, and representing cornified epithelia not undergone fatty 
metamorphosis, in the centre of which is a fatty nucleus. This mass 
represents the contents of one or more acini of a superficially situated 
sebaceous gland, cut oif from the main body of the follicle in the 
manner described above, and always covered when in situ, as Kaposi 
has shown, by a delicate layer of the superimposed corium containing 
papillae. Usually the orifice of the excretory duct cannot be appre- 
ciated in milia, though occasionally these lesions are developed when 
the orifice is patulous. 

These singular 'bodies do not always represent conditions of 
mechanically pent-up sebum, as the epithelia from which their con- 
tents are produced seem at times indisposed to fatty transformation 
and particularly apt to develop into horny or other formations. Thus 
Foster, of Boston, describes one where the process of calcification had 
been apparently complete ; Wagner has observed colloid contents in 
certain opalescent lesions which appeared in the cheeks and temples 
of a woman ; Barensprung and Hebra report numbers of acutely pro- 
duced milia following pemphigus and erysipelas ; and Yirchow and 
Rindfleisch describe milia of the hair-sac and similar lesions accom- 
panied by cyst of the hair-follicle adjacent. It would seem rational 
to conclude that, in cases, the cause of milia is to be sought in obscure 
changes by which the epithelia of the gland are primarily affected. 

Robinson believes that milia originate from miscarried embryonic 
epithelia from a hair- follicle or from the mucous layer of the epi- 
dermis. 

Diagnosis. — Milia might be mistaken for minute vesicles contain- 
ing a milky fluid, but puncture of the lesion, with expulsion of its 
contents, would at once disclose the character of each. Comedones 
with blackish external points, surrounded by the patulous orifice of 
the excretory duct and prolonged more deeply into the substance of 
the skin, could scarcely be confounded with milia. 

The most minute of the lesions of xanthoma have a yellowish 
color and cannot be as readily scraped away from the subjacent tissue 
as can milia. 

Ireatment.— Milia rarely require treatment, as they are usually 
relatively few in number, and produce neither subjective sensation 
nor deformity. If desired, they may be opened w T ith a fine milium 



134 



DISEASES OF THE SKIN 



needle, and their contents turned out, or they may be scraped off 
with the curette. To insure their non-recurrence, the little sac left 
after the operation may be entered with a needle dipped in a fifty 
per cent, solution of chromic acid. This operation may have to be 
repeated in the rare cases where the lesions exhibit a special tendency 
to recur. 

The simplest and most elegant method of removing these aud many 
similar-sized lesions of the skin is by the galvauic battery. With 
from four to six cells in the current, the negative pole is connected 
with a fine needle which is introduced within and beneath the lesion, 
while the moistened sponge of the positive pole is in contact with the 
skin of the patient. The operation is bloodless and effectual ; insig- 
nificant or no scars resulting. 

The prognosis is always favorable. 

[B.] Steatoma. 

Gr. areap, fat. 



Fig. 






■m- 



(Wen, Atheroma.) 

Statistical frequency in America: 0.122. 

Symptoms. — The history of the development and career of wens 
does not greatly differ from that of milia, already described. They 

are usually slow of growth ; unat- 
tended by subjective sensation ; occur 
as single or multiple tumors on the 
head, trunk, or genitals ; and, being 
larger than milia, may attain the size 
of a hen's egg. They are situated 
beneath, within, or upon the skin ; 
are usually unattached to the deeper 
contiguous tissues; and develop into 
irregularly globular, occasionally 
large button-shaped, masses, covered 
by an integument usually unpro- 
vided with hairs. This envelope 
may be quite normal in hue ; or un- 
naturally whitish from pressure ; or, 
especially upon the bald scalp of 
certain fleshy men of middle years, 
reddened, shining, and greasy in ap- 
pearance. At times they are to be 
distinguished only by passing the 
fingers through the long hairs of 
are hidden ; at others, they are so 
conspicuous in consequence of physiological alopecia as to occasion 
considerable disfigurement. They vary greatly in consistency, but 
usually produce to the touch a certain feeling of elasticity, especially 




V 



Cysts of the scalp, one of them being 
laid open to show its contents. (Gross.) 

the scalp, beneath which they 



CYST 135 

if the cyst be tensely distended. They are rarely attacked by in- 
flammation, resulting in suppuration and ulceration. 

Tumors of this kind are rarely exceedingly numerous. MacLaren's 
patient, 1 a lad nineteen years old, exhibited tumors over the entire 
surface of the body, which proved on examination to be sebaceous 
cysts, but which presented ail the appearances of multiple fibromata. 

Pathology. — Wens represent an advanced grade of distention of the 
sebaceous glands by their contents, and a response to the constant 
pressure in hypertrophy of the glandular envelope. Their contents 
are semi-solid, curdy, cheesy, aud granular; or fluid and milky; or 
fluid aud purulent. These are the inspissated or chemically altered 
products of the gland secretion, recognizable as such by the materials 
of which they are composed, masses of fat aud debris of epithelia, 
with an occasional lanugo or undeveloped hair. 

In some cases they are more than mere retention cysts, a benign 
new growth of connective tissue forming the mass of the tumor. 
Calcareous and atheromatous changes in the contents of the cyst are 
common. 

Diagnosis. — Steatomata are to be distinguished from fatty tumors, 
which, however, are more commonly observed about the scapulae, 
loins, buttocks, and extremities ; while wens are very rare except 
about the scalp and neck. They lack also the peculiar u pillowy " 
feel of fatty tumors. Suppurating wens in these regions may readily 
be mistaken for circumscribed abscesses, if regard be not had for the 
history of the tumor usually long preceding. Syphilitic nodes of 
the same part are usually both tender and painful ; osteomata are 
also firmly attached. 

Treatment. — The removal of a wen is accomplished by excision, 
after previous puncture of the sac, and the removal of its contents. 

Several fatal cases, however, are on record as the result of this 
operation ; due not so much to the nature of the excised tumor as to 
its situation, surgical wounds of the scalp being particularly liable 
to erysipelatous and other complications. As the incision required 
for the removal of the wen must necessarily extend for some distance 
on either side of the tumor, a linear scar results which on the bald 
scalp is often very conspicuous as a relic of the lesion. In conse- 
quence of the possibility of danger, many surgeons prefer destruction 
of a prominent section of the mass with acid or alkali, leaving the 
sac, after expulsion of its contents, to wither gradually, though it 
may then be often withdrawn by forceps. 

Complete obliteration is sometimes effected by puncture, expression 
of contents, and the subsequent induction of artificial inflammation in 
the walls of the cyst by injection of tincture of iodine, pure sulphuric 
ether, or other irritating fluids, as in the operation for relief of 
hydrocele. With the antiseptic precautions observed in surgical 
practice to-day, the removal of these lesions from any part of the 
body may be regarded as unattended with great risk. 

i Brit, Med. Journ., Oct. 1SS6. 



136 DISEASES OF THE SKIN. 

Prognosis. — The removal of the wall of the cyst is Dot followed 
by a return of the lesion. In debilitated and cachectic patients there 
may be spontaneous ulceration and sloughing, with or without sur- 
gical interference. Mr. Thomas Bryant 1 reports a carcinomatous 
tumor following the removal of a steatoma from the buttock of a 
woman sixty-three years of age. 



Asteatosis. 

Gr. a, privative ; creap, fat. 

Statistical frequency in America : 0.006. 

Asteatosis is that condition of the skin in which there is absolute or relative de- 
ficiency of the sebaceous secretion. 

Symptoms. — Insufficient lubrication of the skin by its natural 
unguent may be either general or partial, and occur either as an idio- 
pathic or symptomatic disorder. It is produced artificially by any 
agents which continually withdraw the fatty substance from the skin 
surface, as in those trades necessitating the constant immersion of 
any parts of the body in strong alkaline solutions, or waters highly 
impregnated with the salts of lime and potash. As an idiopathic 
affection, it is of very rare occurrence, but it is not an infrequent 
accompaniment of other local or constitutional diseases, such as 
psoriasis, lepra, angioma pigmentosum et atrophicum, ichthyosis, and 
lichen ruber. In these cases the skin becomes dry, often thickened 
and indurated, and, as a consequence, friable, prone to desquamation, 
fissures, and chaps. When handled, the absence of sebaceous secretion 
is noticeable in the objective sensation produced. It is a well-marked 
feature of the marasmus of old age. Some authors have described, 
under this title, the dry thickening and induration of the palm of the 
hand, accompanied by curving of the fingers toward the plane of their 
flexor tendons, which is occasionally to be observed among laun- 
dresses. But considering the absence of sebaceous glands from the 
palm, where in the author's experience this affection is most pro- 
nounced, it should be properly excluded from the list of sebaceous 
disorders. 

Treatment. — No internal medicaments are known to have the power 
of stimulating especially the sebaceous secretion. None, indeed, could 
be capable of having such action when, as is often the case in the 
disorders described above as characterized by asteatosis, there has 
resulted an atrophy of the sebaceous glands. The most that can be 
accomplished is the external application of an artificial unguent ; and 
for this purpose cod-liver oil, almond oil, lanolin, palm oil, vaseline, 
lard, or butter may be employed. Vaseline is in many cases to be 
preferred, as the other articles named are liable to become rancid after 
oxidation, and thus act as irritants to the skin. With such partial 

1 Brit. Med. Journ., May 31, 1884. 



ASTEATOSIS. 137 

or general lubrications, however, a warm bath with soap and water 
should be ordered every second or third day, immediately after which 
the inunction may be repeated. 

Prognosis. — In all those cases where the asteatosis is induced by 
agents operating externally upon the surface, a reasonable hope of 
recovery may be entertained after the withdrawal of the cause. Per- 
sistence of the latter is liable to be succeeded by the occurrence of 
eczema or dermatitis medicamentosa. A complete cure can scarcely 
be expected when this condition is really a symptom of one of the dis- 
orders already named. 

Congenital Fibro-sebaceous Disease. — Crocker reports two 
instances, occurring in infants who exhibited signs of the disease at 
birth, in which patches with an area of u several square inches" were 
visible on the face, the front of the neck, and in front of and above 
the ear. These were slightly raised, pale reddish-yellow in color, 
finely granular over the surface, and consisted of closely aggregated 
pale-yellowish, pin-point sized papules, the patches being sharply 
defined with many comedones at the borders. The growths, on 
section, seemed to be due to a fibrous hypertrophy resulting in 
atrophy of the hair-follicles and coil-glauds, and separation of the 
lobes of the sebaceous glands. 

Multiple Dermoid Cysts. — These occur in cases, either as few 
or more often exceedingly numerous, uncolored or yellowish-white 
lesions, pin's-head to small-nut sized, strongly resembling multiple 
fibromata, but all containing a sebaceous or cheese-like matter when 
incised and the contents expressed. Jamieson, Hebra, Rayer, Pol- 
litzer, 1 and others have reported these cases, the last-named observer 
finding a well-defined cyst wall with cystic contents consisting of 
typical epithelium transformed into horny cells undergoing fatty 
degeneration. 

Bare Consequences of Sebaceous Cystic Disease are re- 
ported by a few authors, such as Cook, Hutchinson, and others, in 
cases where steatomata in typical situations have broken down into 
ulcerations ; in still others fungous tumors have formed of consider- 
able size requiring surgical attention. 

1 Amer Journ. of Cutaneous and Genito-Urinary Diseases, Aug. 1891. 



138 DISEASES OF THE SKIN. 

CLASS II. 

INFLAMMATIONS. 

Exanthemata. 

Gr. etjavdrj/ua, blossoming, flowering. 

The Exanthemata are specific fevers, frequently occurring in epidemic form, com- 
municable by contagion, preceded by a period of incubation, and characterized 
by systemic disturbance, with an efflorescence upon the skin, of different type 
in each, as also by involvement of other organs of the body, a single attack 
often conferring immunity upon an affected individual during his or her life- 
time, against subsequent attacks of the same disease. 

For a detailed consideration of the phenomena of the exanthematons 
fevers, the reader is referred to the standard treatises on the subject, 
in the field of general medicine. Brief space is allotted here, merely 
to a description of the cutaneous lesions by which they are severally 
characterized. These are unlike in each disease ; and yet all exhibit 
certain common characteristics. In all, the eruptions are symmetrical ; 
and in typical cases, general. In each, the efflorescence is succeeded 
by a desquamative or exfoliating condition of the skin. In each 
there is, within relatively fixed limits, a distinct stadium of the 
pathological process, within which it is completed, and beyond which, 
however persistent may be its remote sequelae, there is no chronic 
manifestation of the disorder. Each also is produced solely by its own 
specific contagium, derived exclusively from an animal body affected 
with the same disease, being never, so far as known, generated from 
any other source, nor merging by imperceptible degrees the one into 
another. Two of these may rarely concur, but under such circum- 
stances the one is always more pronounced in its features, which either 
closely precede or follow those of another. No specific medication is 
known to be capable of arresting any one of them, each pursuing its 
course uninterruptedly to a favorable or fatal termination, according 
to the intensity of the poison present in each case, and the more or 
less favorable or unfavorable conditions of the sufferer. Finally, it 
seems probable that, at no distant date, specific bacteria or micrococci 
will be demonstrated to be etiological factors in the production of each. 

Morbilli. 
(Measles, Rubeola ) 

Measles is a specific, contagious, febrile disorder accompanied by a cutaneous 
exanthem and an acute catarrh of the mucous surface of the respiratory tract. 

This disease is preceded by a period of incubation lasting from 
eight to twenty-one (usually from ten to twelve) days, a period in 



MORBILLI. 139 

which there may be no evidence of ill health, or merely a moderate 
degree of lassitude and inappetence. To this succeeds a prodromic 
fever, the temperature rising to 103°-104° F., occasionally alter- 
nating with chills, or a sensation of chilliness, dryness of the skin, 
pains in the head, thirst, occasionally sweating, rarely convulsions in 
children, and, almost invariably, a serous catarrh of the mucous sur- 
faces. By the second or third day the temperature begins to decline, 
while the catarrhal symptoms increase. These are manifested in 
sneezing, a copious secretion from the eyes and nose, aud engorgement 
of the exposed mucous surfaces, especially of the conjunctiva, nares, 
and throat. Occasionally, the tongue aud fauces exhibit a few isolated, 
minute, reddish puncta. In consequence of the implication of the 
larynx, trachea, and ultimately the larger bronchi, there is a hoarse, 
frequently an incessant and teasiug cough, of a convulsive character, 
accompanied by expectoration of mucus in moderate quantity. This 
prodromic period lasts from three to five days, but is, iu exceptional 
cases, prolonged to twice that length of time. Upon its conclusion, 
the exanthem appears, usually on the fourth day, with aggravation 
of the fever, the temperature rising to 104°-106° F., and remaining 
at that point till the eruption has reached its apogee, when it com- 
monly declines pari passu with the severity of the skin symptoms. 

The eruption of measles usually appears first upon the face (the 
forehead and temples), and thence extends in about thirty hours over 
the neck, upper portion of the trunk, and superior extremities. 
Between the fourth and sixth days of the disease it has usually 
attained its deepest shades of color, and its maximum of development 
over the entire surface of the body, including the palms and soles. 
This maximum attained, the eruption gradually fades ; the tumid 
condition of the skin, most noticeable on the face, also subsides ; the 
catarrhal symptoms and cough become less annoying; and the patient 
enters upon the period of desquamation. 

The eruption is characterized by the occurrence of reddish, yellow- 
ish-red, mulberry-red, deep raspberry-red, or, in extreme cases, vio- 
laceous-tinted, small finger-nail sized maculae, either not elevated or 
very slightly raised above the general level of the integument; or 
by the occurrence of large pin-head sized, discrete papules, much 
more rarely pin-point sized vesicles, corresponding in color to the 
shades described above, and highly suggestive of the first efflores- 
cence in variola. These lesions become pale under pressure, exhibit- 
ing then a yellowish tint, and are often set together very closely, 
particularly over the upper segment of the body, in patches suggest- 
ing a crescentic outline. The term " suggesting " is here used pur- 
posely, as it is difficult, by selecting a single patch, to determine by 
the eye alone the existence of such a configuration ; while yet an 
examination of the eruption as a whole may often very clearly convey 
this impression to the sight. In other words, the crescentic outline 
is far less distinct than, for example, in certain of the papulo-crusta- 
ceous syphilodermata. Usually, patches of sound skin can be 
recognized, even when the eruption appears to be confluent, complete 



140 DISEASES OF THE SKIN. 

confluence never occurring so as to form a sheet or mask over an 
entire area of the skin. Individual lesions may so merge as to be 
well-nigh indistinguishable separately ; yet, on the whole, the erup- 
tion deserves fully the plural character of its English name. It is 
made up in all cases of innumerable elements, whose identity is never 
wholly lost. The subjective sensation awakened is occasionally a 
severe itching or burning ; frequently this is a matter of insignifi- 
cance in comparison with other disagreeable symptoms — e. g., the 
cough, coryza, and fever. 

Desquamation is accomplished usually with cessation of fever and 
the production of yellowish-brown pigmentations of the surface 
where the elements of the eruption have existed, involution being 
first manifested in the site of the lesions which were earliest to 
develop. Gradually aud simultaneously, the catarrhal symptoms of 
the respiratory passages diminish in severity. This final stage of 
the disease is usually terminated in a fortnight from the date of 
invasion. 

The complications and anomalies of measles depend : upon the 
intensity of the poison, displayed in the most formidable symptoms 
where human beings are crowded together, as in camps and prisons ; 
upon the degree of physical vigor ; and also upon the various 
hygienic surroundings of the victims of the disease. Thus, the 
period of efflorescence may be unusually prolonged ; the eruption 
may disappear suddenly, and as rapidly reappear ; the cutaueous 
symptoms may alone be wanting; the latter may be commingled 
with petechias due to cutaueous extravasatiou of blood, which may 
be also accompanied by severe epistaxis ; and the catarrhal condition 
of the mucous surfaces affected may terminate in croupal or diphthe- 
ritic disease, may be followed by capillary bronchitis, catarrhal 
pneumonia, and even by pulmonary tuberculosis. Typhoid condi- 
tions may also supervene, and chronic inflammatory affections of the 
eyes and of the Sohneiderian membrane result. 

The pathology of the cutaneous lesions in measles is that merely 
of acute hyperemia occasionally passing into exudation, limited for 
the most part to the vascular papillae of the corium and the peri- 
follicular plexuses of bloodvessels. Post-mortem, the eruption fades, 
as the result of the gravity of the blood, from the anterior aspect of 
the body as it reclines upon the dorsum. 

While it is possible that the cause of this disease will be one day 
demonstrated to depend upon some of the inferior organisms, no 
observer can yet claim to have conclusively established the fact. 
Bacteria, of small size and great mobility, have, been found in the 
blood by Coze and Feltz ; microcooci in the trachea by Klebs ; 
spherical bodies in the breath of children, and, post-mortem, in the 
lungs and liver by Braidwood and Vacher 1 ; and similar organisms 

i Braidwood and Vacher (Trans. Path. Soc. of Lond., 1878, pp. 422-423) described sparkling 
staff-shaped fusiform or ovate bodies slightly tinged with carmine, which were supposed to be 
the " micro-organisms with which the contagium of measles is intimately associated." These 
were carefully distinguished from the forms of micrococci found in inflamed tissue, though 
effects from pure cultures had not been produced. It is, however, interesting to note that 



MORBILLI. 141 

in the vesicles and pustules of malignant measles by Keating and 
Formad. 1 

The disease is one of infancy chiefly, probably because at that age 
there is always the largest number of individuals unprotected by 
previous attacks. In every case, the malady results from contagion, 
mediate or immediate, from an infected human subject. It spares 
no age or sex, though much rarer in advanced years than at other 
periods of life, probably because of the large number who, at such 
period, enjoy immunity. 

The diagnosis of importance is between scarlatina and variola. 
Typical cases with a well-developed eruption can be scarcely mis- 
taken for either, if the symptoms displayed are assigned their full 
weight. It would be useless, however, to deny the fact that atypical 
forms occur, which have again and again confused the most expert 
diagnosticians ; and in all cases of doubt the prudent practitioner 
will refuse to decide as to the nature of the disease till the symptoms 
have, in the lapse of time, been fully declared. The resemblance 
between illy-developed measles and certain of the eruptions seen in 
varioloid, is in the highest degree striking; and the greatest skill, at 
a given moment of time, will in cases utterly fail to make a decision 
between the two. A distinctly crescentic character of the eruption, 
the presence of catarrhal symptoms, the continuance of the fever 
after the efflorescence is completed, the color of the eruption, and the 
discovery of the nature of the disease from which the contagion was 
derived, will all point in the direction of the truth. From scarla- 
tina, measles is much more readily differentiated by the macular or 
papular elements of its eruption ; by their color; by their appear- 
ance to a marked degree upon the face ; and by the absence of the 
characteristic sore throat and usually intense febrile access of the first 
named disease. From the various forms of erythema accompanied 
by fever, measles can always be distinguished by the irregularity of 
the temperature record, as well as by the character of the eruption. 
The distinction between rubeola and rotheln is given later. 

The treatment of measles should be strictly limited to a careful 
hygienic attention to the invalid, including a restricted " fever diet," 
and the use of such medicaments only as are especially indicated. 
The antithermic remedies employed in the general management of 
the febrile process may be required in special cases. 

In the way of local treatment, the skin should be anointed with 
a bland, oily, or fatty substance, to relieve the pruritic sensations, 
especially after the sponging of the surface once daily with a weak 
alkaline solution, which may be used cool without fear of producing 
" repercussiou " of the exanthem. The chamber of the invalid 
should be somewhat darkened for the sake of the eyes, but pure air 
should be constantly admitted. 

more recently Canon and Pielicke have made observations confirming in part this discovery. 
They recognized the bacilli in fourteen instances in the blood as also in secretions from the 
nose and conjunctivse, and in lung tissue after death from measles. These organisms were 
cultivated with marked success in bouillon. 
1 See Sternberg's Magnan's '• Bacteria." New York, 1884. 



142 DISEASES OF THE SKIN. 

The prognosis is, in general, favorable. All the complications 
named above increase, however, the gravity of the disease, which is 
also enhanced among men crowded together in camps, children in 
public charities, pregnant women, the cachectic and greatly enfeebled 
from other diseases, very young infants, old men and women, and 
residents of islands that have been long unvisited by epidemics of 
the malady. 

The disease has been demonstrated to produce itself by contagion 
two to four days before the appearance of the rash, while the power 
of such transmission is usually lost between the twentieth and thir- 
tieth days after the exanthem is fully developed. 



Rotheln. 
(Rubella, German Measles, Hybrid Measles, French Measles.) 

Rotheln is a specific, feebly contagious, febrile disorder, often epidemic, accom- 
panied by a characteristic exanthem. 

The disease has an incubative period lasting from fourteen to 
twenty-one days, followed either by the eruption or by brief pro- 
dromes lasting from a few hours to a single day. These are feelings 
of malaise, cephalalgia, articular pains, anorexia, and nausea. The 
occipital, cervical, and other glands may at this time become large 
and tender. After a pyrexic period, rarely lasting longer than a 
few hours and in many cases entirely absent, the eruption appears, 
occurring for the most part in the regions affected by measles ; in 
the form of multiple, pin-point to small pin-head sized macules, but 
smaller than the lesions displayed in that disease, and decidedly 
lighter in color. The shade is rosy to a crimson-red, rarely lurid, 
never of dark mulberry or violaceous hue. This color will, at times, 
be perceptible beyond the line of the lesions, in a delicate halo, a 
circumstance which strongly distinguishes the exanthem from mor- 
billi. The lesions, moreover, are very seldom arranged in crescentic 
outline, being more often grouped in roundish or oval patches. Often, 
indeed, the elements of the eruption are discrete and disseminated. 
The fauces are occasionally reddened in puncta. The eruption com- 
monly fades in from one to two days, and there may or may not be 
slight resulting cutaneous desquamation. 

The rash is to be distinguished from that of measles by the recog- 
nition of the features described above, particularly by the color, 
contour, and date of occurrence of the exanthem ; the transitory 
character of the fever when the latter is present ; the cervical aden- 
opathy and the rapidity with which involution of the disease pro- 
gresses. By the temperature record alone of the patient, it may be 
differentiated from scarlatina, though the rash is dissimilar in the 
two diseases. It is also not to be confounded with the erythematous 
affections of the skin. One of the most striking characteristics of 
the disease can be best recognized in a ward filled with children, all 



SCARLATINA. 143 

of whom are simultaneously affected with the disorder. That char- 
acteristic is the remarkable mildness of the phenomena displayed in 
every case. The author has had under observation at one time 
twenty little patients all exhibiting the exanthein, not one of whom 
presented the peculiar facies of the sufferer from measles. 

After an exhaustive study of this disease, Atkinson 1 concludes 
that while its characters are so denned as to justify a reasonable cer- 
tainty in its diagnosis, it has no symptom that is not often assumed 
by measles. 

The disorder should be treated by rest in bed, a supply of fresh 
air, the strictest attention to asepsis, and the usual diet of fever 
patients. Medication by drugs is almost never indicated. 

Scarlatina. 
(Scarlet Fever, Scarlet Rash, Canker Rash.) 

Scarlatina is a specific, contagious, febrile disorder, characterized by a cutaneous 
exanthem, and by involvement of the throat and other bodily organs. 

The period of incubation of scarlet fever varies between twenty- 
four hours and a month or more, the average duration being about 
eight days. The reason of this wide variation is to be sought, not 
in any changeability in the mode of evolution of the disease, but in 
the fact that its poison is less volatile aud less rapidly dissipated than 
is that of measles, the result being that it may remain potential for 
longer periods in connection with articles through the medium of 
which it is transferred from one individual to another. This incu- 
bative period, like that described in connection with measles, may 
be quite unproductive of physical symptoms, or be associated with 
an ill-defined malaise. 

The prodrome of the disease in typical cases, is marked by the 
occurrence of a rapid and bounding pulse, an exceedingly dry skin, 
and a characteristic sore throat. When examination of the mouth 
is made, the tongue is seen to be thickly coated, and its filiform 
papillae reddened and prominent, producing the so-called " straw- 
berry appearance." The velum, pillars of the fauces, tonsils, and 
all exposed mucous surfaces are engorged, tumid, reddened, and 
often covered with deep reddish puncta, which unquestionably rep- 
resent hyperemia of the peri-follicular tissues. Thirst is great, and 
deglutition often in the highest degree painful. In severe cases, the 
mucous surfaces named may speedily exhibit finger-nail to pigeon's - 
egg sized, ashy ulcerations with a lurid halo at the periphery. In 
children, there may be syncope, delirium, convulsions, vomiting, or, 
when the poison has been intense, fatal results from shock of the 
nervous centres. This prodromal period usually lasts from twelve 
to twenty-four hours, though it may be prolouged for two days 
more. In this respect scarlatina is markedly distinguished from 

i Amer. Journ. of the Med. Sci., 1887. 



144 DISEASES OF THE SKIN. 

measles. This stage is terminated by the appearance of the exan- 
them, but the fever persists without abatement after the explosion ; 
and the other symptoms of the disease are then in no wise amelio- 
rated. 

The eruption in scarlatina usually spares the face, however much 
the latter may display two damask-colored cheeks under the febrile 
flush, become tumid with the acceleration to it of the blood pumped 
through the throbbing carotids, or even exhibit a few scanty lesions 
upon the forehead and temples. About the mouth the integument 
is always pallid. This is far different from the picture presented in 
measles. The eruption is first seen in the form of light or deep red, 
pin-head sized puncta, so closely agglomerated as to produce upon 
the eye the impression of a diffuse reddish blush. It is first seen 
about the neck and clavicular regions, but rapidly spreads to the 
trunk and extremities, including the dorsal surfaces of the hands 
and feet, attaining complete development in the course of the second 
day of the eruption. It is then of a distinctly scarlet color, whence 
the disease has its name in the Latin, English, and German tongues, 
a coloration frequently compared to the appearance of a boiled lobster. 
Upon the limbs it is often developed in punctate form, while the 
occurrence of a diffuse scarlet blush is most distinctly perceived by 
the eye in the examination of the trunk. Here it is seen to fade 
under pressure ; and the finger-nail drawn rapidly over the surface 
of the skin is followed by the formation of a whitish line, which 
persists for an instant, a time sufficient to enable one to describe a 
letter upon the skin. This period of efflorescence lasts for from one 
to two days to an entire week, during which, as stated above, the 
febrile and other symptoms continue unabated. 

The rash usually persists at its maximum of development for from 
one to three days, the concomitant symptoms continuing without 
noticeable abatement. Among the latter may be named the occur- 
rence of albumin in a urinary secretion of diminished specific gravity, 
with occasionally the presence of epithelium recognizable under the 
microscope as derived from the lining membrane of the uriniferous 
tubules of the kidney. 

Having attained its apogee, the eruption in favorable cases begins 
to fade, the part first affected exhibiting earliest a lighter shade, while 
the other pathological phenomena diminish in severity, the sore 
throat especially in ulcerated conditions, alone persisting. In from 
four to ten days longer the eruption disappears, leaving a brownish - 
yellow pigmentation of the surface ; and simultaneously the other 
symptoms of disease vanish. 

The desquamation which then ensues, as convalescence progresses, 
is general and often proportioned in extent to the severity of the 
preceding eruption, though it may be generalized after a well-nigh 
imperceptible exanthem. It is more pronounced and characteristic 
in scarlatina than in any of the other eruptive fevers. It may be 
superficial and furfuraceous in character, or the epidermis may fall 
in lamellated plates, the sheath of an entire finger, for example, with 



SCARLATINA. 145 

the nail, or that of the entire palm. In this way sheets, ribbons, 
and shreds of the horny layer of the skin may fall from its surface 
and expose beneath a new and often tender epidermis. The hairs 
may be simultaneously shed. When this desquamation is finished 
the stadium of the disease may be regarded as concluded, the entire 
period lasting in uncomplicated cases from a fortnight to a month or 
six weeks. 

The complications, anomalies, and remote sequelae of scarlatina are 
so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need be merely reminded in these pages 
that the usual incubative and prodromic stages of the disease may be 
brief as to time, or so brusquely followed by eruptive phenomena as 
to be indistinguishable. The latter may also first occur upon the 
extremities or trunk, and later on the neck and over the clavicles ; or 
at once cover the totality of the surface by a rapid explosion, or be 
extremely short-lived, or be altogether absent, or be unusually pro- 
longed and visible for even a fortnight upon the surface of the body, 
appearing and well-nigh disappearing without appreciable cause. 
To a proportionate extent, the stage of desquamation may be preco- 
ciously or tardily reached, and the exfoliating process be tediously 
prolonged and of intense type, jeoparding in this manner the future 
of the convalescent prostrated by the fever which has passed or the 
sympathetic fever which may thus be awakened. 

The anomalies of the scarlatinal rash are numerous, but depend, in 
general, less upon a variation in the intensity of the poison than upon 
the physical condition of the patient. Thus, the affected surface may 
be slightly elevated above the general level; there may be no coin- 
cident pyrexia ; it may exhibit irregularly disposed mottlings aud 
maculations, may be characterized by the occurrence of miliary pap- 
ules, minute vesicles, or purpuric lesions, well defined against the 
general scarlet color of the skin by their violaceous shade, and due 
to cutaneous extravasation of blood. The rare bullous, pustular, and 
urticarial lesions which may appear upon the skin are accidental and 
bear no relation to the specific history of the disease. 

Malignant anginose scarlatina is characterized by the gravity of 
the throat symptoms. In such cases a parenchymatous inflammation 
of the tonsils, velum, and fauces supervenes at an early period, with 
enormous tumefaction ; involvement of the submucous tissue and 
neighboring glands ; and ulcerative, suppurative, and even gangrenous 
results, which may prove speedily fatal. Gastro-intestinal disorders 
may also prove dangerous. An otitis externa, media, or interna, 
may perforate the tympanum, destroy the ossicles, induce caries of 
the mastoid process of the temporal bone, and prove fatal by the 
eventual production of meningitis or phlebitis. 

Another severe type of the disease is that in which symptoms of 
typhus are pronounced (Scarlatiniform Typhus). Here the 
patient may perish within a few hours after being attacked and before 
the eruption appears, exhibiting comatose or convulsive symptoms 
indicating the profound influence upon the nervous centres of the 

10 



146 



DISEASES OF THE SKIN, 



intensely intoxicated blood ; or the eruption may have time to appear, 
often livid, hemorrhagic, or petechial in type, and be followed by 
albuminuria, meningitis, diarrhoea, coma, and death. Catarrhal and 
parenchymatous nephritis is justly dreaded during the desquamative 
period of the malady, when it may prove fatal after a relatively 
benignant manifestation of the disease in its prodromal and eruptive 
stages. To this sufficiently grave list of disorders which may com- 
plicate scarlet fever must be added pneumonia, pericarditis, pleuritis, 
peritonitis, chronic purulent nasal catarrh, which may result in caries 
of the nasal bones, destruction of the cornea as a result of severe 
keratitis, persistent adenopathy of the subcutaneous glands, and 
malnutrition in many forms, which may so impair the vigor of the 
constitution as to leave the sufferer a physical wreck for the remainder 
of life. 



Fig 37. 




Microphotograph of the edge of 
a. Central zone. 



i small colony of the bacillus scarlatinee. 
b. Outer edge of growth 



The cutaneous lesions of scarlatina, like those of rubeola, depend 
upon hyperemia and a moderate degree of exudation. The latter, 
when it occurs, is limited for the most part to the rete and papillary 
layer of the corium. The signs of the disorder are not apparent in 
the dead body, unless there has been exudation of blood and the 
consequent formation of petechia?. 

The disease is produced exclusively by contagion derived from the 
animal body affected with scarlatina, either mediately or immediately. 
It attacks individuals of both sexes and all ages, children and infants 
more frequently, the aged more rarely, probably in consequence of 
their respective conditions as regards immunity conferred by a previous 



SCARLATINA. 147 

attack, since, in general, the disease occurs but once in a lifetime. 
Individual idiosyncrasy must account for the cases in which unpro- 
tected infants exposed to the disease fail to receive it, a fact noted 
occasionally in all the exanthemata. The contagious element is 
volatile in its nature, and seems to be most active during the eruptive 
stage of the disease. 

Rod-like bodies and mobile points have been found by Reiss, 
Coze, and Feltz, in the blood of patients affected with scarlet 
fever; and injection of rabbits with such blood has proved fatal. 
Drs. Jameson and Edington 1 have recognized and cultivated the 
"bacillus scarlatina?," measuring 0.4 m.m. in thickness and 1.2-1.4 
m.m. in length, forming long, jointed, and curved, motile leptothrix 
filaments. Exceedingly interesting clinical facts as to the trans- 
mission of scarlatina through the medium of the milk of diseased 
cows have been determined by some of the local health boards in 
Great Britain. The disease at times follows injuries and surgical 
operations, due, as Atkinson supposes, 2 to diminished powers of 
resistance to the disease. 

The diagnosis is between measles, rotheln, erysipelas, and the ery- 
themata ; and is, in general, readily established. The sore throat, 
intense fever, punctiform scarlet rash reaching to the border of the 
inferior maxilla, and the distinct, whitish-yellow line traceable by the 
finger-nail passed rapidly over the surface, are all characteristic. In 
measles, the macular character of the rash, and its crescentic arrange- 
ment, in connection with the catarrhal symptoms, will usually be 
recognized. From erysipelas, scarlatina can always be distinguished 
by the absence of the peculiar, shining, smooth, or glazed and tumid 
condition of the affected area. From all other rashes, scarlet fever 
can be distinguished by the pyrexic symptoms and resulting des- 
quamation. 

Great care should be taken not to confound the medicinal rashes 
having a scarlatiniform appearance with the specific disease under 
consideration. Thus belladonna, in doses of one minim of the tinc- 
ture every hour to the extent of four doses, has produced an abund- 
ant scarlatiniform eruption in children, a diagnostic point of impor- 
tance in view of the fact that the drug named is employed popularly 
as a prophylactic against the disease. For the medicinal eruption of 
this sort due to quinine and other drugs, the reader is referred to the 
pages devoted to dermatitis medicamentosa. 

The modern treatment of uncomplicated scarlatina is antiseptic 
and expectant, after provision is made for an abundant supply of 
fresh air, disinfection, a proper regulation of food and drink, and the 
local use of baths, tepid or cool, for the purpose of reducing the 
bodily temperature. After each of these, the skin should be com- 
pletely anointed with a fatty substance, such as cold cream, scented 
almond or olive oil ; or, what is most commonly used in this coun- 
try, vaseline. These inunctions are not only grateful to the patient, 

i British Medical Journal, June 11, 1887, and August 6, 1887. 

2 Journal of Cutaneous and Venereal Diseases, vol. iv, October, 1886. 



148 DISEASES OF THE SKIN. 

but reduce the temperature to a slight degree. All other treatment 
than that suggested above, should be limited to the special conditions 
presented in each case, and pertains to the field of general medicine. 
It includes the management of disorders of the eye, ear, throat, kid- 
neys, and other viscera, whose involvement constitutes a complica- 
tion of the disease. 

The prognosis of the malady should always be established with 
reserve. It is largely based upon the relative intensity of the symp- 
toms, the vigor and age of the subject, and the presence or absence of 
serious complications. Albuminuria is rarely absent, and not per se 
alarming ; but anasarca and other evidences of profound interference 
with the renal function, are to be assigned due weight. In general, 
it may be said that a high range of temperature ; early and ulcerative 
throat lesions ; tardy development, rapid and untimely disappearance, 
or undue prolongation of the exanthem ; and its admixture with 
petechia? to such an extent as to indicate extensive hemorrhagic ex- 
travasation are all formidable symptoms. Finally, it must not be 
forgotten that the mildest and simplest forms of the disease, after the 
fastigium is passed and convalescence actually established, may ter- 
minate fatally by the supervention of uraemia, cerebral paralysis, or 
even meningitis, consequent upon secondary changes in the middle 
or internal ear. 

Variola. 

Lat. varus, a blotch. 

(Smallpox.) 

Variola is a specific, contagious, and febrile disorder characterized, when un- 
modified, by the appearance in succession upon the cutaneous surface and occa- 
sionally also upon the mucous surfaces, of papules, vesicles, pustules, crusts, and 
cicatrices. 

The variations of this malady as to the severity, character, and 
duration of its symptoms, are so great as to preclude its complete 
description within the limits here assigned to the subject. The fol- 
lowing paragraphs are devoted to a brief sketch merely of its more 
commonly recognized characters. 

The period of incubation of the unmitigated disease varies between 
ten and twenty days, occupying usually a fortnight. It is character- 
ized by the peculiarities of that period recognized in all the exan- 
themata, few and insignificant or no evidences of physical discomfort. 
The prodromic stage is ushered in generally by a vespertine chill, 
succeeded by fever, with a temperature rising to 104°-106° F., which 
is commonly associated with severe and characteristic pain in the 
loins, headache, nausea or vomiting, and occasionally, in young sub- 
jects, delirium and convulsions. The fever continues, with alterna- 
tions of exacerbation and partial relief, or sensations of chilliness, on 
the second and third days. At the same time there may be faucial 
hyperemia and moderate dysphagia. Occasionally, before the cuta- 



VARIOLA. 149 

neous exanthem appears, minute reddish papules may be recognized 
upon the buccal membrane. 

On the second and third days there appears, in some cases, espe- 
cially in menstruating women and in young subjects, a cutaneous 
efflorescence, whose significance has been often misinterpreted and 
which has led to many errors in diagnosis. It is to Hebra that we 
are indebted for its distinct recognition as a cutaneous prodrome in 
variola. It has been termed Variolous Erythema, and Vario- 
lous Roseola. Its recognition is a matter of special importance to 
the diagnostician, as many have been deceived respecting its nature 
and significance. It is characterized by the occurrence of irregularly 
disposed and distinctly outlined maculatious, puncta, striae, streaks, 
or a diffuse blush of bright or lurid reddish hue ; the invaded integu- 
ment being at times slightly tumid, and thus elevated above the 
general level. It may be also the seat of moderate pruritus. The 
blush may fade under pressure, but rarely does so perfectly. Oue 
cannot by the finger produce upon it a visible whitish spot. It occurs 
most often about the groins, hypogastric region, pubes, and inner 
faces of the thighs ; and, examining these parts, the physician will 
usually discover the evidence, in adult women, of recent or present 
menstruation, or of the puerperal state. It occurs also about the 
axilla?, the extensor faces of the larger and smaller joints, and the 

lumbar and clavicular regions. Often a broad area of the integument 

p & 

in these parts may exhibit a sheet or mask of dull crimsou erythema, 
upon which pin-hpad to bean-sized, dull-reddish papules may form, 
not losing -their color under pressure, more rarely petechia?, vesicles, 
and wheals. All these are precursory phenomena, and are not trans- 
formed into characteristic variolous lesions. They fade almost com- 
pletely before the latter appear. Rarely, a few scattered papules may 
be distinguished upon the face and arms before the variolous erythema 
fades. Often the former in full development are even less profusely 
displayed in the site of the precedent efflorescence. The latter need 
not be necessarily regarded as a symptom of portentous gravity. The 
author has seen the entire surface of the belly covered with a uniform 
erythematous blush of dull crimson hue, confluent variola follow, and 
the patient ultimately recover. The physician, then, in the face of a 
deep red erythema of the regions named, especially of the groins, 
lower part of the belly, and thighs of a menstruating woman affected 
with high fever, nausea, vomiting, and lumbar pain, should invariably 
suspect the presence of variola. 

The period of eruption is characterized, at its earliest, by puncti- 
form, subcutaneous discolorations which photography alone can reveal. 
Commonly, after three days of prodromic symptoms, the patient will 
be seen on the morning of the fourth with the face and scalp covered 
by pin-head sized and larger, firm, conical papules, whose impression 
to the finger is compared by most English writers to the feeling of 
shot. Later, these develop upon the trunk and limbs ; and in well- 
marked cases every portion of the surface of the body is invaded, 
including the palms and soles. The lesions may be surrounded by a 



150 



DISEASES OF THE SKIN. 



narrow rosy areola upon the trunk. They may be unproductive of 
subjective sensations, or be slightly tender. 

As a rule, there is complete defervescence when the exanthem 
appears, the patient experiencing such relief that if an adult has 
chanced not to view the face in a mirror nor to be informed of his 
appearance by those in attendance upon him, he will often regard 
himself as completely relieved of his three days' illness. In other 
cases, the febrile symptoms persist, with a lowered temperature. 

During the first two days of the eruptive period, the papules in- 
crease in number, and become correspondingly agglomerated ; while 
those of earliest appearance become transformed into vesicles con- 
taining a translucent serum, the roof- wall of many of them exhibiting 
an umbilication. This umbilication of the vesicle is characteristic, 




Vertical section of pustule at the beginning of pustulation a, umbilication at the site of 
an excretory canal ; b, reticulum within the epidermis ; c, reticulum of smaller meshes con- 
taining lymph- and pus-globules. (After Rindfleisch.) 

and slightly different from that observed in bullous and pustular 
lesions. The central depression is disproportionately large, and 
about it the yet undistended epidermis is often irregularly puckered 
or fluted. Even in this period, the lapse of a few hours will produce 
a lactescent appearance in their formerly translucent contents. 

From the eighth to the twelfth day, the transformation of these 
lesions into pustules is effected, the process beginning, as in all the 
metamorphoses of the disease, in the vesicles of greatest age ; those, 
namely, on the face and upper portions of the body. The lesions 
simultaneously enlarge till they are of the average size of a pea, and, 
being fully distended, rupture the centrally placed filament which 
held down the roof-wall, in consequence of which the umbilication 
of the pustules is lost. With this process of suppuration, is 
awakened the so-called secondary fever, a pathological process evi- 
dently not essential to the disease, as it does not occur in mitigated 



VARIOLA. 151 

cases. It is born of the extensive process of suppuration occurring 
in the skin and other organs, and may be symptomatic, sympathetic, 
or septicemic in character. It thus varies in different cases with 
the character and severity of the process by which it is excited, 
being transitory in mild cases, and in others terminating only with 
death. At this time the patient is usually in a most distressing con- 
dition. The skin of the face and other attacked regions is swollen, 
thickly covered with pustules, and the features indistinguishable in 
the tumid and closed lids, the oedematous lips, disfigured nostrils, and 
pus-obstructed mucous outlets. Deglutition becomes painful and 
often impossible ; the saliva flows from the lips ; and the mucus of 
the nares dries with the pus upon the exterior of the visage. The 
pustules recognized upon the integument are represented also in the 




Vertical section of one-half of an undeveloped pustule, a, old epidermis ; b, epithelia of rete 
above the alveoli ; c, new-formed epidermis ; d, alveoli filled with pus-globules ; g, flattened 
and infiltrated papillse lying beneath the pustule. (After Auspitz and Basch.) 

gastro-intestinal tract. In an autopsy of a patient dead at this stage 
of the disease, made by myself in company with Dr. McGill, of the 
United States Army, we discovered the entire canal from the mouth 
to the anus, as also the genito-urinary and respiratory passages, com- 
pletely covered with closely agglomerated and well distended pus- 
tules. The career of those within the mouth can be usually studied 
by observation with the eye. In this situation they rapidly lose 
their epithelial roof- wall by reason of the heat, moisture, and friction 
to which they are subjected, and then exhibit a reddened and exco- 
riated surface, over which there is reformation of the epidermal 
layer. Gangrenous complications are rare. 

Between the thirteenth and fourteenth days desiccation begins, and 
is usually completed within from ten days to a fortnight afterward ; 
the pustules rupture, and the exuded pus concretes into yellowish 
and brownish, rarely blackish crusts, or the latter are formed by the 



152 DISEASES OF THE SKIN. 

desiccation of the entire envelope and contents. The pulse usually 
at the same time diminishes iu frequency ; a secondary defervescence 
occurs ; the tumefaction of the integument decreases ; and at times 
the peculiarly characteristic, and often intolerably fetid odor of the 
patient is less perceptibly exhaled. In from four to six weeks the 
course of the disease is completed. The immediate traces of the 
eruption are purplish and violaceous pigmentations, which slowly 
disappear. When cicatrices result, they are slightly depressed, dead- 
white, lustrous, usually symmetrical in disposition, and most distinct 
upon the surfaces exposed to the light and air, as the face. Though 
persistent, they are rendered somewhat less deforming in the progress 
of years. When closely set together, they produce a characteristic 
ridged and corded appearance, due to the elevation of narrow bands 
of unaffected integument between the depressed surfaces of scars. 

The several departures from the pronounced type of the disease 
described above present variations differing widely from the most 
benignant forms. Brief reference only can be made to these. 

Varioloid, whether occurring after vaccination or not, is a modi- 
fied form of the disease. With it should be classed all those forms 
of the disorder occurring in the human subject, and described by 
authors under the title of " Swine-pox," " Horn-pox," etc. In these 
cases there may be severe prodromic fever and a scantily developed 
exanthem ; mild fever, abundant exanthem, and rapid involution of 
lesions ; abortion of the latter in any of their several stages from 
papule to crust ; absence of secondary fever ; transmission of the 
disease in a mild or mitigated form, from one individual to another, 
so that an entire community, vaccinated and unvaccinated alike, may 
suffer from an epidemic disorder of this moderate grade without the 
occurrence among them of a single case of typical Variola. It is 
scarcely necessary to add that the patient with varioloid, especially 
during an epidemic, may transmit to the unprotected a malignant 
form of the disease. 

Much more formidable, viewed from every standpoint, is Hemor- 
rhagic Variola, fortunately rare and too often confounded in the 
past with " black measles." When cutaneous haemorrhages occur 
during the course of smallpox, they do not necessarily indicate that 
the case is one of the so-called varioliform purpura, since these may 
be accidents of the pathological process. In this malignant form of 
the disease, against whose ravages vaccination often presents a feeble 
barrier, the prodromic stage is followed by a deep purplish redness 
of the surface which is characterized by pin-head to split-pea sized, 
firm, closely set, papular lesions, suggesting the occurrence of measles 
in a peculiarly severe form. The febrile, nervous, and other symp- 
toms of the disease are proportionately intense. Ecchymoses appear 
upon the conjunctival membrane. Gradually the color of the exan- 
them, which at first disappeared under pressure, refuses thus to 
yield, and assumes a bluish-black shade. Ecchymotic patches may 
be intermingled with these, rapidly widening to palm-siz^d and 



VARIOLA. 153 

larger areas. The raucous surfaces share in these colors, being also 
infiltrated with effused blood; and the mucocutaneous orifices are 
crust-covered and exhale an extreme fetor. Blood may escape from 
the bowels, bladder, mouth, and vagina. Signs of grave systemic 
and visceral complications are always present. Vesiculation, pustula- 
tion, and the typical transformations of the variolous lesions are all 
wanting. In the few cases observed by the author, death has always 
speedily supervened, either from shock, coma, hemorrhagic infarc- 
tion of the lungs, or rapid exhaustion. Intermediate forms between 
hemorrhagic and true variola are described, in which the pustules 
occurring in the latter form of the disease merely fill with blood in 
consequence of accidents possessing a purely local significance. 

The Confluent is another severe form of variola, less malignant, 
however, than that just described. It is characterized by intensity 
of the prodromic fever, which often scarcely abates with the appear- 
ance of the exanthem. The latter is developed in deeply implanted, 
firm papules, closely set together, succeeded by vesicles and pustules, 
which, as they enlarge, fully occupy the entire surface of the integu- 
ment, and accomplish a perfect coalescence. In well-marked cases 
there is scarcely a pin-head sized area of the entire surface of the 
body which is not invaded. The tissues become enormously oedema- 
tous ; the deformity of the face renders the features indistinguishable. 
Hemorrhagic pustules and even patches of a gangrenous pulp may 
be intermingled with the sheets of suppurating surface. Phouation, 
respiration, and deglutition are proportionately impeded or absolutely 
subverted by the tumefaction and suppuration of the mucous mem- 
branes of the respiratory and gastro-intestinal tracts. When the 
patient survives till the stage of desiccation is reached, the body pre- 
sents an aspect as revolting as that ever displayed by a living being. 
A thick, brownish, or blackish-brown mask envelopes the swollen 
head, trunk, and limbs ; and the odor exhaled from the body is 
intolerably repulsive. All the systemic phenomena are proportion- 
ately grave and accompanied by one or more of the complications of 
the malady, pneumonia, pleuro-pneumonia, albuminuria, diarrhoea, 
various motor and sensory paralyses, subcutaneous furuncles, and 
abscesses. The eyes may suffer from pustular and ulcerative changes 
in the conjunctiva, cornea, and deeper tissues, with resulting inflam- 
mation of every grade to panophthalmia, and resulting loss of vision. 
Often the patients, with surprising powers of resistance, will survive 
till extensive sheets of crusts have fallen from the surface, and then 
perish slowly in a typhoid condition with low remittent or continuous 
fever. Every such case does not, however, conclude fatally. Chil- 
dren may rally from the severest form of confluent variola, and 
enjoy afterward a vigor which illustrates well the wonderful recu- 
perative energy of the natural forces under the most adverse circum- 
stances. 

Variola is always the result of mediate or immediate contagion. 
It is a disease which is both contagious and infectious, being trans- 
missible by volatile emanations from the victims of the disease. It 



154 DISEASES OF THE SKIN. 

is also artificially inoculable. When transmitted by the latter pro- 
cess, its period of incubation is somewhat shortened, and often its 
successive manifestations become then less formidable. The history 
of inoculated human variola has, however, received but little atten- 
tion during the last decade, in which the practice has been properly 
forbidden by law. The disease is, to a certain extent, transmissible 
from man to the lower animals, and the reverse. It attacks indi- 
viduals of both sexes and all ages, including the foetus in utero, 
which may be ushered at an untimely hour into the world macerated 
or recently dead and covered with the lesions of variola. The disease 
in the larger cities is decidedly more frequent in winter than in 
summer, possibly because in the colder months the opportunities are 
greater for spreading the contagion in artificially heated dwellings 
where numbers of individuals are crowded together. Islanders long 
unvisited by an epidemic and unprotected by vaccination, may suffer 
equally in the summer season. 

The parasitic nature of variola has not yet been demonstrated. 
Coze, Feltz, Baudouin, Luginbuhl, Weigert, Hallier, and Cohn have 
recognized micro-organisms, both bacteria and micrococci, in the 
blood of variolous patients. None of these have as yet been utilized 
in the production of the disease ; but Cohn 1 regards these parasites 
as a twin race of the micrococcus vaccinae discovered in vaccine 
lymph. The secondary fever of the disease is without question 
septicemic and due to the pus cocci and their toxine. 

The difficulty attending the diagnosis of variola in its prodromic 
and earliest eruptive stages, from rubeola, has been already men- 
tioned. The general demand, indeed, upon the physician for an 
exact and definite diagnosis of every case before its typical develop- 
ment, is founded upon an erroneous conception of possibilities ; and 
the sooner this is generally recognized, the better for all concerned. 
A delay of even a few hours will often verify or remove a suspicion, 
and the author is confident that he has seen fully as much mortifica- 
tion on the part of the physician and damage to the best interests of 
the patient, result from an error in one direction as in the other. 
The wisest course in every doubtful case is to admit the doubt and 
to visit the patient frequently for the purpose of observing the de- 
velopment of the disease till that doubt is removed. Typical cases 
of variola are recognized with ease from the character of the symp- 
toms presented. Syphilis and acne are always distinguished by the 
absence of fever and their relative chronicity. Two cases of sud- 
denly occurring medicamentous acneiform rash have come under the 
author's observation, where a diagnosis of variola had been pre- 
viously made. In each, the absence of a prodromic stage and the 
subjective sensation excited, were sufficient to point to the nature of 
the disease when considered in connection with the peculiar character 
of the lesions. 

The prognosis of variola is largely dependent upon the degree of 

1 See Magnan, loc. cit., p. 411. 



VARICELLA. 155 

protection conferred by previous vaccination. This aside, the age 
and vigor of the patient, the presence or absence of an epidemic of 
severe or mild type, the extent of the eruption, and the character of 
the surroundings of the patient, are elements of prime importance. 
Very young and aged subjects, women pregnant or in the puerperal 
state, and, as Hebra has shown, those who have suffered from a pre- 
vious attack of the same disorder, are all unfavorably related to the 
final result. Confluent and hsemorrhagic forms of the disease are, 
naturally, the gravest. Unmitigated variola is, under the most favor- 
able circumstances, one of the greatest scourges of humanity ; and 
as such will probably always destroy a frightful proportion of its 
victims. At the same time, the conscientious physician needs to 
be impressed with the fact, that under the most discouraging circum- 
stances, the patient, disfigured to the greatest extent by an envelope 
of blackened crust, and in a state of extreme physical prostration, 
with many of his bodily functions almost completely suspended, may 
even from the midst of such peril be won back to life and vigor. 
The assiduous attentions of a gentle nurse, guided by the inspiring 
presence and counsels of a physician who is himself fearless of the 
malady, will often achieve the result. Upon the latter point, it is 
interesting to note, that physicians in active practice who do not 
hesitate to expose themselves freely to the disease in the discharge of 
the duties of their profession, rarely suffer in their own persons. 

Varicella. 
(Chicken-pox.) 

Varicella is a contagious, febrile disorder of benignant and mild character, 
accompanied by a vesicular exanthem. 

The disease has an incubative period lasting for about a fortnight, 
after which there is occurrence of malaise, chilliness, and languor. 
The patients are usually children who may suffer thus from fever of 
a moderate grade lasting from a few hours to two or three days, after 
which defervescence is commonly complete. With its onset, or with- 
out it, the rash appears, first on the head and trunk, in the form of 
rosy maculae or slightly elevated lesions lacking the characteristic 
" shot-like " feeling of the variolous papule. These rapidly become 
vesicular, the lesions being pin-head to pea-sized, limpid, superficial 
in situation, differently shaped and very rarely umbilicated, puckered, 
or " fluted" as in smallpox. They appear in successive crops, and 
are often surrounded by a faint halo. Their contents become cloudy 
or lactescent rather than puriform, and desiccate often as early as the 
second day, forming thin, light, superficial crusts. The lesions may 
be abundant in one region, as, for example, over the back or the 
chest ; but are practically never both abundant and generalized, and 
never confluent. Like variolous lesions, they extend at times to the 
mucous surfaces of the eyes, mouth, and genital regions. Occasionally 
they are productive of pruritic sensations. Often the course of the 



156 DISEASES OF THE SKIN. 

disease is so mild and the exanthem so slight as scarcely to attract 
attention. Cicatrices result only in places, chiefly the face, where the 
lesions have been subjected to local irritation. 

Diagnosis. — It is well known that a number of German authori- 
ties, following Hebra, have given assent to the doctrines taught by 
the latter that varicella is only a mitigated form of variola. That 
doctrine is offensive to American and English physicians, who in 
practice find it vastly wiser to distinguish carefully and exactly be- 
tween the diseases in question. The settlement of the discussion may 
well be relegated to a date when the probable parasitic nature of both 
disorders can be exactly determined. 

In variola, the invasion period, of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of the 
patient, the thermic variations, the prodromic rashes, and the speedy 
transformation of the papules into umbilicated vesicles, are all impor- 
tant diagnostic points In varicella, the trunk usually exhibits the 
greater number of lesions, which appear also in successive crops. 
Beside the characteristics of the cutaneous lesions, the catarrhal symp- 
toms of measles and the sore throat of scarlatina, will point to the 
nature of these disorders. Fox's impetigo contagiosa is to be very 
carefully distinguished from varicella, since the two affections occur at 
times side by side in one hospital ward ; and occasionally the former 
succeeds the latter. The lesions of impetigo contagiosa are often 
larger, generally more persistent, the crusts bulkier, and the patients 
may be of a more advanced age. 

The treatment of variola should, in general, be limited to the indi- 
cations presented in each case. No remedies can be employed which 
have the least power to abort the disease. Kaposi calls attention 
to the striking fact in this connection, that in syphilis, for many of 
whose manifestations mercury is a specific, we find a disease whose 
second incubative period is measured by weeks, and yet neither by 
excision of its initial sclerosis nor by mercurials can the subsequent 
manifestations of the disease be completely prevented. Certainly, no 
specifics are recognized as of value in variola. The patient should 
be kept in a relatively darkened room with au abundant supply of 
fresh air of a uniform temperature ; and antiseptic solutions should 
be constantly at hand into which all the ejecta are immediately 
received. He should be given ice when this is grateful to the palate, 
cool water ad libitum, and his strength should be sedulously supported 
by a liquid animal diet. The body may be sponged with or bathed 
in cool or tepid water, as often as is grateful to the patient. In severe 
or confluent cases, the constant immersion of the body in the continu- 
ous warm water bath, as practised in Vienna, is followed by the most 
brilliant results in hastening the desiccation and fall of the crusts and 
the subsequent repair. A bath of this character given for merely two 
or three hours in the day, is often of great value. With and without 
these external measures, gargles of chlorate of potash, myrrh, honey, 



VACCINIA. 157 

or carbolic acid, will be found acceptable to the mouth and palate. 
Indeed, the constant attention of an efficient nurse bestowing assidu- 
ous care upon the mouth, skin, and eyes, may be regarded as an 
esseutial part of all sound treatment. 

As regards the prevention of pitting, it may be remarked that no 
measures of a therapeutic character will prevent the occurrence of 
a distinct cicatrix whenever pus has eroded or otherwise destroyed 
the integrity of the papillary layer of the corium. Every effort, 
therefore, should be exerted to prevent the extension of the suppura- 
tive process to the true skin. The following are measures which have 
approved themselves as of practical value : first, the sick-room should 
be moderately darkened, and yet amply provided with fresh air; 
second, a solution of the hyposulphite of sodium (Squibb's is supe- 
rior to the ordinary preparations in the market) should be adminis- 
tered night and day in the dose of from fifteen to twenty grains 
(1.— 1.3) every three or four hours. Certainly the variolous lesions 
pursue a milder course under this internal treatment, and even, in 
cases, the vesicles shrivel before pustulation is fairly begun. Third, 
the skin of the face should be anointed with a bland fatty substance 
such as vaseline, almond oil, or fresh lard, and over this may be laid 
silk-enveloped compresses, dipped in tepid and weak solutions of 
carbolic or boric acid, or thymol. The anointing of the surface 
before the application of the lotion is commonly more grateful to the 
patient, but the skin may be constantly moistened with the aqueous 
lotion alone. Here, again, the assiduous attention of the nurse is a 
matter of importance. The powder of iodoform topically is often 
applied with advantage. 

The edges of the eyelids should be daily anointed with freshly pre- 
pared cold cream. Puncture of the cornea may be required for the 
relief of hypopion. Diarrhoea and other symptoms of visceral de- 
rangement should be relieved by appropriate medication. As a rule, 
the administration of narcotics for the relief of pain is objectionable. 
Throughout all, the strength of the sufferer should be supported by 
a general use of animal broths or milk ; and in typhoid conditions 
a judicious employment of stimulants may be necessary. 

Vaccinia. 

(Cowpox.) 

Vaccinia is a specific bovine fever, accompanied by a vesicular exanthem, trans- 
missible to man by inoculation. 

The limits of these pages forbid a discussion of the interesting 
questions which concern the relations of cowpox as it occurs sponta- 
neously in the milch-cow, to human variola. A careful collation of 
the results obtained by the large number of vacciniculturists of later 
days, renders it clear that it is a matter of great difficulty to transmit 
variola from man to the heifer ; that where this rare result is ob- 
tained, the lymph derived from the lesions on the udder or the belly 



158 DISEASES OF THE SKIN. 

of the latter is liable to produce variola when retransmitted to man ; 
and that spontaneous cowpox alone seems to furnish a lymph which 
is safely inoculable in generations to the human race. 

Of greater importance is it to note here that, either by arm-to- arm 
vaccination, as was formerly extensively practised, or by the use of 
the animal virus which has of late been well-nigh exclusively em- 
ployed in this country, there has been conferred upon millions of 
human beings a degree of protection against variola whose value is 
beyond estimate. In both methods, the lymph is derived originally 
from the female of the bovine race, preferably in the puerperal state ; 
and its sources are the vesicular lesions of vaccinia spontaneously 
arising or artificially cultivated about the teats, udder, and adjacent 
parts. The introduction of this lymph into the skin of the human 
subject is termed vaccination. 

The simple operation of vaccination is performed in many ways, 
but that which especially commends itself to the prudent man is the 
method which eliminates to the largest extent the possibility of trans- 
mitting any other contagious disease than the one intended. With 
this object in view, no better instrument can be devised than a clean 
needle, one which has been properly disinfected and not previously 
employed for any purpose. The skin of the part selected for vacci- 
nation being first cleansed antiseptically, and subjected to slight 
tension by the left hand, the vaccinator should scratch or scrape off 
the epidermis with the needle, held in the right, by a series of parallel 
and crossed strokes, so as to make three or four superficial erosions, 
at a distance of three or more inches apart. Each of these multiplex 
wounds should have the size of the little finger-nail, and should in 
no case bleed, but merely ooze with serum slightly tinged with blood. 
At such points the lymph is to be thoroughly and slowly rubbed 
in, whether it be supplied in a dry form upon ivory points which 
have been dipped in the serum oozing from vaccine lesions upon the 
heifer, or be a fluid obtained by crushing and dissolving in water the 
crust taken from the similar lesions on the arm of a child previously 
unprotected and recently vaccinated. In public charities, where, for 
the most part, such procedures are practicable, it is usually sufficient 
to dip a needle into the lymph flowing from the arm of the vaccini- 
fer and to plunge it, thus charged, once or twice into the part selected 
for the operation. 

Between the third and fourth days after a successful vaccination 
of the unprotected, a light reddish, pin-head sized papule rises at 
each inoculated point. Between the fifth and sixth days, it becomes 
transformed into a translucent, well-distended, occasionally umbili- 
cated vesicle. This, when single, may attain the size of the finger- 
nail. Springing from the multiplex abrasions described above, a 
minute papule usually forms at each point of intersection of the 
crossed lines produced by the scratching with the needle, and the 
subsequent vesicles coalesce, forming thus a compound lesion of 
rather peculiar aspect. It appears often as a small coin-sized plaque, 
elevated to the extent of a line or more beyond the general level, 



VACCINIA. 159 

with a rim formed of numerous discrete or confluent vesicles, which. 
in either case are closely set together. The compound plaque seems 
to develop afterward as a single lesion, its centre being depressed. 
After the ninth day, the fluid becomes opalescent, and desiccates in a 
reddish-brown crust, which, examined in section by a good light 
after it is completely dried, exhibits a smooth, homogeneous, shining 
appearance, with a color having the shade of amber. 

Fully as important as any of these metamorphoses of this lesion, 
is its rosy-reddish areola, in the absence of which some authorities 
declare that there is not proper protection. It completely encircles 
the compound vesicle in the form of a halo having a diameter of 
several inches, the tissue it invades being often slightly tumid. When 
the pathological process in the focus of this areola is intensified, 
either as the result of the irritant character of the virus, or from 
extrinsic causes (undue exertion of the vaccinated part), the areola 
may spread extensively down the arm, or over the thigh or leg, and 
eventually cover a dense, brawny, and deeply reddened integument. 
Dermatitis, erysipelas, lymphangitis, adenopathy, and severe grades 
of inflammation of the subcutaneous tissues, may for similar reasons 
complicate the process, which may terminate by central sloughing, 
ulceration, slow repair, and the production of an atypical cicatrix. 
Ordinarily, the subjective phenomena are limited to a mild or annoy- 
ing itching of the vaccinated surface ; in other cases, severe burning 
pain, a feeling of tension, and even sympathetic fever may be 
aroused. 

The acme of a successful vaccination is usually attained between 
the tenth and the fourteenth days, after which the symptoms of the 
disorder gradually subside, the crust falling, if undisturbed, in the 
course of the ensuing week. When " animal " virus is employed, 
the duration of each of these stages of the disease is usually some- 
what prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually 
assumes the dead white appearance of scars in general. When 
typical, it is slightly depressed, circular, not irregular, nor deformed 
by ridges, cords, or bands, and " foveolated," exhibiting a series of 
peripheral pits or depressions, each of which represents the site of a 
former minute vesicle of simple type. There is strong reason to 
believe, in the face of authoritative statements to the contrary, that 
the degree of protection is based in part upon the multiplicity of 
typical cicatrices, and, in view of the rarity of variolous patients 
with four such traces of successful vaccination upon the person, 
many are prejudiced in favor of the English method of producing 
multiple scars. 

The complications of vaccination are due, first, to the character of 
the virus employed ; second, to the character of the soil in which it 
is implanted ; and third, to the external accidents to which the vac- 
cine lesion is subjected. Respecting the first of these sources, there 
are few contagious diseases which may be transmitted by vaccination, 
beside syphilis. When this accident occurs, it may be due either to 



160 DISEASES OF THE SKIN. 

the fact of syphilis in the vaccinifer, or to the use of instruments 
soiled with infectious secretions. It is both asserted and denied, that 
the lymph from a typical vacciue vesicle in a syphilitic vacciuifer 
will necessarily transmit syphilis, if it be accidentally commingled 
with either blood or the products of inflammation at the base of the 
pock. The demonstration of any such fact requires a mass of evi- 
dence exceedingly difficult to collect, inasmuch as the stage and 
intensity of the disease in the vaccinifer are elements which cannot 
be ignored in a decision of the question. When thus transmitted, it 
will be remembered that the vaccine lesion may complete its career 
during the incubative period of the initial sclerosis, whose existence 
at the site of vaccination is commonly declared later by induration, 
ulceration, pigmentation, and axillary adenopathy. The occurrence 
of a generalized syphiloderm before the chancre of vaccination is 
completely healed, is often the first symptom to arouse suspicion. 
Those further interested in the subject should study the cases collected 
and admirably illustrated by Mr. Jonathan Hutchinson, 1 of London. 
It should be added, that the popular impression regarding the fre- 
quency of this accident is greatly erroneous. In the experience of 
the author the rarest of all modes of transmission of syphilis is that 
by vaccination. In all such cases, the possibility that the syphilis 
may be hereditary, and its symptoms simply coincident in point of 
time with those of vaccinia, should not be forgotten. 

Exceedingly dangerous is that virus, however good its early char- 
acter, in which decomposition or putrefactive changes have occurred 
after exposure, in a liquid form, to the action of heat and the atmos- 
phere. Vaccination with lymph thus changed has been rapidly 
followed by fatal results, in consequence of the supervention of 
pyaemia or septicaemia. 

Complications of vaccinia, due to the character or predisposition 
of the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or prejudiced to the causes just con- 
sidered. Post hoc ergo propter hoe is the sole logic of the uninformed. 
In this way almost all other ills of the human family have been in 
turn ascribed to " impurities " and " humors " introduced by vaccina- 
tion. The language and arguments used in support of these positions 
have been as extravagant as they were unreasonable, and have borne 
fruit in the refusal of many physicians of repute to perform vaccina- 
tion and thereafter to assume the responsibility of all the subsequent 
ailments of the vaccinated. The cutaneous symptoms which may 
thus be awakened are numerous. It will be remembered that the 
contents of the typical vaccine vesicle are auto-inoculable, and that 
thus the scratching of young patients may produce an abundant crop 
of typical or torn vesicles upon the arms, legs, thighs, hands, and 
fingers. But vaccination may also awaken in the patient, as ex- 
plained above, a latent syphilis, as also a list of cutaneous disorders 
not contagious in character. Thus an erythema (roseola vaccinia, 
vaccinola, etc.), eczema in many of its forms, and other exudative 

1 Illustrations of Clinical Surgery. Phila., 1875. 



VACCINIA. 161 

processes may be first aroused in the integument by the turbulence of 
a successful vaccination. 

These rashes may become generalized, and even assume a formid- 
able appearance. They may appear at auy time from the second to 
the fourteenth day after vaccination. A scarlatiniform rash, diffused 
or in patches, is described by some authors as occurring in this way, 
accompanied by mild fever, and resembling German measles. Simi- 
larly generalized eruptions, resembling erythema multiforme, psoriasis, 
urticaria, impetigo contagiosa, varicella, and other cutaneous disorders, 
may appear for the first time within the limits named above. They 
usually disappear within a brief time after the vaccine vesicle has 
completed its involution, and may be followed by slight desquama- 
tion or pigmentation. 1 

Very rarely vaccinia is followed by pupuric symptoms. 

Anomalies of the vaccine vesicle are occasionally noted as to its 
shape, career, and resulting cicatrix which it is difficult to explain. 
Thus, the papulo-vesicle may not exhibit an umbilicated centre, or 
may complete its course within unusually short limits ; or a harmless 
ulceration may progress beneath its crust, requiring a week, or even 
more, for complete cicatrization. The so-called " raspberry sore " is 
explained by Robinson as resulting from coalescence of small papules, 
so as to form a pigmented tubercle. The scars resulting from many 
of these irregular and non-protective results of vaccination may in 
each direction form a typical cicatrix, being, on the one hand, small 
palm-sized, deforming, corded, and representative of large tissue-loss ; 
and, on the other, feeble, irregular, and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of 
the lesion are usually inflammatory in character. The excessive use 
of the vaccinated arm in labor, and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis, and even ulcerative changes in the site of the 
inoculation, as a result of the intensity of the process. For these 
accidents rest is essential, with the free use of a dusting powder over 
the inflamed surface. In exaggerated cases, lotions of lead-water 
and opium may be employed. These conditions are usually relieved 
without difficulty as soon as the part is put to rest. The atypical 
scar which results seems to be in such cases as protective as others, if 
only the accident have occurred to a typically progressing lesion with 
distinctly perfect areola. Vaccine cicatrices are to be distinguished 
in anomalous situations from maculae atrophica, the scars of syphilis, 
and of other scar- leaving disorders. 

Micrococci have been recognized by Cohn in vaccine-lymph. These 
have been named micrococci vaccinas, but their relation to similar 
organisms discovered in the blood and tissues of variolous patients 
has not yet been determined. Wolff 2 claims to have cultivated these 

1 An interesting paper on vaccinal eruptions was read by Dr. Gustav Behrend, before the 
Dermatological Section of the International Medical Congress, in London, August 5, 1881. (See 
a translation of his paper by Dr. Alexander, Arch of Derm., No. 4, 1881, vol. vii. p. 383.) 

2 Berl. klin. Wochenschr., January 22, 1883. 

11 



162 DISEASES OF THE SKIN. 

organisms through fifteen generations. Strauss has demonstrated 
their existence in the vaccinal pustules of the calf. 1 

Lipp, of Gratz, reported to the International Medical Congress, in 
London, that he had recognized great similarity, if not identity, 
between the micrococci of vaccinia and variola, which he had culti- 
vated to the second generation, but had then been unsuccessful in 
producing inoculation effects. These organisms were always arranged 
in groups of four, or multiples of four. 



Erythema Simplex. 

Gr. kpWrj/ia, redness. 

(Rose rash. Fr., Erytheme ; Ger., Hautrbthe.) 

Statistical frequency in America, 0.859. 

Erythema Simplex is a coloration of the skin in various shades of redness, 
temporarily disappearing under pressure, the lesions differing in size and shape 
according to the extent and degree of the hyperemia by which they are 
induced. 

Hypersemia of the skin, due to increased velocity or amount of the 
fluid in the cutaneous capillaries, results in increased coloration of 
the integument. The shades of this color vary from a delicate pink 
or rosy hue to a dark reddish color. Thus, hypersemiaB may be dif- 
fuse or circumscribed, idiopathic or symptomatic, and due to active 
or passive congestion of the vessels. 

Idiopathic Erythema. 

Erythema Traumaticum. — Here the redness is the result of 
friction, rubbing, pressure, scratching, and similar external contacts. 
It is observed, for example, in the part pressed by the pad of a truss ; 
in the colored circle left about the leg where a tight garter has been 
worn ; on the sides of the nose where pressure is exerted by a newly 
applied pair of eye-glasses. These traumatic hyperemias are readily 
converted into exudative affections, if the traumatism be long con- 
tinued. Intermittent pressure upon the skin permits restoration of 
the vascular equilibrium, and the skin responds to the demand made 
upon it, by increasing in thickness; continued pressure, on the con- 
trary, admits of no such restoration ; and the integument finally 
becomes thinner, and yields before the agent inflicting the injury. 
Inflammation resulting in ulceration may finally supervene. 

Erythema Caloricum. — Solar heat in excess and extremes of 
cold ; very hot and very cold water ; and other heat-conducting sub- 
stances, are also sufficient to induce transitory redness of the surface. 
In the erythemata induced by solar heat especially, there is frequently 

See Magnan, loc. cit. 



ERYTHEMA SIMPLEX. 163 

an increase in the pigmentation of the surface, as in the production 
of freckles and " tan " in persons whose skins are reddened by the 
sun. The darker, brownish, and chocolate-colored stains of the hands 
and face are thus induced. 

Erythema caloricum (Erythema ab Igne) may occur in annular and 
odd-looking gyrate patches on the anterior faces of the legs in cooks, 
firemen, stokers, and persons exposing that portion of the body to 
the direct action of heat. The annular patches may be several cen- 
timetres in diameter, and vary in shade from a light to deep red or even 
purplish tint, deep pigmentation resulting as the erythema subsides. 

Erythema Vekenatum. — A number of chemical substances, 
dyes, and vegetable poisons are capable of producing transient hyper- 
emia of the skin. Among these may be mentioned cantharides, 
capsicum, mustard, aniline, chloroform, ether, arnica, and several of 
the essential oils. 

Erythema Gangrenosum. — Under this title several singular 
affections of the skin have been described, in which erythematous 
patches appeared and were followed by more or less extensive 
destruction of one or more of the several layers of the skin. T. C. 
Fox, in a description of the appearances in two cases under his 
observation, concludes that these are the symptoms of a feigned 
disease, or one produced artificially for the purpose of exciting 
sympathy, etc. 

Symptomatic Erythema. 

This may be of either active or passive form. A long list of 
physiological and pathological causes operating upon the system at 
large are capable of inducing active symptomatic hyperemia of the 
skin. This may be generally diffused, or occur in surface mottlings 
and markings of various sizes and shapes. Thus, the skin of the face 
may be intensely reddened in a paroxysm of rage ; and that of the 
limbs of a teething child covered with rosy maculations in consequence 
of the reflection to the surface, through the medium of the nervous 
system, of the irritation induced by eruption of a tooth. In conse- 
quence of the rosy tint assumed by several of these rashes, they 
have long been termed "roseola," a name which to-day is held to 
describe a symptom rather than a disease. The word "roseola" is 
still associated in the minds of many with the earliest syphiloderm ; 
but that eruption is now designated by the best authors as the 
erythematous or macular syphilide. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a speedy efflorescence 
of this character. A lurid erythema of the axillary or inguinal 
region may precede by several days the eruption of confluent variola. 
Cholera, cerebro-spinal meningitis, enteric and other fevers are thus 
at times accompanied, preceded, or followed by rashes. A study of 
these is of the utmost importance to the diagnostician. Children 



164 DISEASES OF THE SKIN. 

who are really susceptible to the disease are often supposed to possess 
an immunity from scarlatina, as the symptomatic erythema pre- 
viously displayed was misconstrued. 

Symptomatic passive erythema is usually characterized by a 
cyanotic, purplish, or darker hue of the integument, resulting largely 
from accumulation in excess of carbonic acid in the blood. The 
temperature of such skins is either normal or below the normal 
standard, as in those cases where gangreue ensues. A long list of 
conditions may be named in which these symptoms may be noted, 
including derangement of the bloodvessels from imperfect innerva- 
tion, direct pressure, or disease of the heart or vascular walls. 

These erythemas may be either circumscribed in area or general. 
The term u livedo " is applied to circumscribed regions of passive 
erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this 
form of disease. The so-called symmetrical gangrene of the fingers 
belongs to the same category. Cardiac cyanosis, or morbus cseruleus., 
is a name given to a generalized dark blue discoloration of the entire 
surface, due often to continued patency of the foramen ovale. 

Erythema Pernio (Pernio, "Chilblains") is a form of this 
affection occurring in persons having a feeble circulation, usually in 
the young and the very old. The redness is most conspicuous, as a 
rule, on the hands and feet, merely because of the distance of these 
organs from the centres of circulation. The redness is of either a 
light or dusky shade; is accompanied by tenderness, itching, and 
burning sensations, especially when the part is brought near an 
artificial source of heat ; and may be the origin of exudative and 
other affections of the skin, though the ulceration and sloughing 
which occur in extreme cases are really the results of freezing the 
organs rather than of simple exposure to cold when the circulation is 
impaired. 

The diagnosis of all these varieties of hyperemia is readily made 
when it is observed that the redness disappears on pressure and also 
that the parts are actually cool rather than hot, the coolness being 
appreciable by the touch. Not rarely they are both cool and moist- 
ened with sweat. The treatment is by brisk friction, and stimulat- 
ing lotions, such as camphorated soap liniment ; acetous, spirituous, 
and vinous lotions; or the use of the ordinary "bay rum" of the 
shops. Afterward the parts should be well dusted with boric acid, 
and all woollen stockings discarded for the feet. 

Erythema Paratrimma is a term once employed for the form of 
deep and lurid redness preceding the formation of a bedsore, an ac- 
cident that in the modern methods of nursing is as obsolete as the name 
once given it. 

Erythema L^eve is an obsolete term once employed to desig- 
nate the shining redness of the skiu in oedema of the lower extremi- 
ties following any disorder sufficient to induce such local tume- 
faction. 



ERYTHEMA SIMPLEX. 165 

Diagnosis. — If an erythema of the surface exists and is manifestly 
unattended by exudative symptoms, the recognition of the condition 
of the skin is not difficult. A more serious problem, however, con- 
cerns the significance of this symptom when it occurs in connection 
with grave constitutional maladies. A high temperature, severe 
lumbar pain, great gastric or intestinal irritability, coryza, and injec- 
tion of the ocular conjunctivae, are symptoms which should always put 
the practitioner on his guard in pronouncing upon the nature of an 
erythema. 

On the other hand, patients in a state of alarm frequently seek 
relief for an idiopathic erythema, of the nature of which they are 
ignorant. Here the locality, contour, and general appearance of the 
eruption, taken in connection with the history of the case, will usually 
suffice to establish a diagnosis. 

Treatment. — The symptomatic erythemata are usually of such 
trifling significance in comparison with the constitutional disorder by 
which they are occasioned, that the removal or management of the 
latter becomes of the higher importance. The idiopathic erythemata 
are usually relieved at once by the suspension of the cause Occa- 
sionally cold water, weak spirit lotions, dilute solutions of carbolic 
acid, or one of the dusting powders may be required. The ordinary 
rubber, adhesive, or lead plaster, may be applied to erythematous 
surfaces where the friction must be necessarily continued (surgical 
appliances, orthopaedic apparatus, etc.), and in those produced by 
constant pressure (nates and sacrum in low fevers or surgical confine- 
ment), it should never be forgotten that the hyperaernic is also a 
weakened skin. Here stimulating applications may be needed, alco- 
holic, camphorated, etc., with a view to the restoration of the tone of 
the weakened capillaries. 

Erythema Scarlatiniforme. (Scarlatinoid Erythema, Des- 
quamative Scarlatiniform Erythema, Scarlatino'ide, Erythema Puuc- 
tatum, Roseola Scarlatini forme; " Scarlet Rash;" Erytheme In- 
fectueux.) 

This disorder is declared by prodromata of malaise, slight or severe 
rigors, and a general feeling of lassitude succeeded by fever attain- 
ing its maximum in the course of two or three days. Suddenly 
appear, minute, punctiform lesions, or scarlet-tinted papules, which 
may coalesce, with however defined limitations, especially on the face. 
The subjective sensations are burning, smarting, and itching. As 
distinguished from scarlatina, which it somewhat resembles, there 
may be a beginning of the eruptive features on the lower extremities, 
spreading thence upward, or the reverse ; and this extension may be 
quite rapid, so that the exanthem may become universal in a few 
hours. In the course of a few days desquamation ensues with exfoli- 
ation of large lamella? from the surface, the epidermis of the palms and 
soles being shed in a single sheet resembling those cut for the manu- 
facture of kid-gloves. Relapses may occur from time to time, though 
the first attack is usually most severe. 



166 DISEASES OF THE SKIN. 

Under this title, as Brocq has well shown, are included several 
differing conditions. In one class may be named those best described 
under the titles, pityriasis rubra and exfoliative dermatitis. In a 
second may be named the cases resulting from septicemic, blen- 
norrhagic, and other poisons. Such are the cases reported as oc- 
curring in typhoid fever (Ohmann-Dumesnil, August, 1890). In 
yet a third class are those which result from drug-ingestion or ex- 
ternal application — the medicamentous rashes. Given a suscepti- 
bility to any specially irritating cause, and these recurrent rashes, 
even with extensive desquamation, may occur. 



Erythema Intertrigo. 

Lat. inter, between ; terere, to rub. 

Erythema Intertrigo is a hypersemic condition of those cutaneous and muco- 
cutaneous surfaces which are in constant apposition, and between which there 
is a hypersecretion or retention of sweat. 

Symptoms. — The erythema which is limited to portions of the 
integument which lie in contact with each other is subject to certain 
modifications. The sites of such contacts in the human body are the 
axillae, the groins, the cleft between the nates, the inter-mammary 
and infra-mammary spaces in women, the superior and inner faces 
of the thighs, the scroto-femoral and the labio-femoral clefts in the 
sexes respectively, the flexures of the joints, and in especially fat 
individuals, all those parts where the integument is thrown into fleshy 
folds, as about the neck of infants, and even over the crest of the ilia 
in fat women. In these localities the disorder, beginning as an 
erythema traumaticum, proceeds by its irritative effects to stimulate 
the secretion of sweat, which is freely poured out between the adjacent 
folds of the skin, and may there be temporarily imprisoned. The 
surface, heated and reddened, is also somewhat macerated by the 
effused perspiration ; and the latter, when chemically altered, as it is 
frequently under these circumstances, adds still further to the original 
disorder. The ground is thus well prepared for an exudative process, 
but the disorder may be limited to mere hypersemia with hyperidrosis, 
and disappear before the supervention of actual inflammation. 

The sensations produced are those of heat and tenderness. When 
the parts in contact are separated the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macerated 
epidermis become evident. One such is always especially significant, 
of is the linear and superficial excoriation which marks the line of 
deepest contact of the two apposed surfaces of the skin at the bottom 
It the angle formed by the two. An offeusive odor usually proceeds 
from the part in consequence of the fluid secreted. Fox, of Loudon, 
has called attention to the fact that the secretions of an intertrigo 
stain, but do not stiffen the linen of the patient, and thus differ from 
the serous fluid poured out in an exudative dermatitis. 



ERYTHEMA INTERTRIGO. 167 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture — these causes occasionally co-operating. The heat may be 
merely that of the natural temperature of the body, or it may be 
increased by that due to season and climate. The friction also may 
be merely that originating between the surfaces in apposition, or may 
be increased by clothing or other articles worn next the skin. The 
moisture which produces maceration of the epidermis is that origi- 
nating in the perspiratory follicles, their secretion being doubtless 
stimulated by the heat and friction. The interchange of operation of 
these three factors is, lastly, shown by the fact that the friction, if 
severe, is capable of increasing the temperature of the part to which 
it is applied. 

As aggravating causes may be named other physiological secretions 
and excretions, retained in contact with the surfaces affected with an 
intertrigo. Thus, the feces of the infant left in contact with its nates 
upon the napkin ; the urine of the old man with paralysis of the 
bladder, or with "overflow" from prostatic disease; the milk of the 
nursing women dribbling over the breast to the infra-mammary 
region ; retained lochial, menstrual, and similar discharges, are all 
efficient in this regard, and particularly apt to induce that form of 
dermatitis to which the intertrigo then plays a subordinate part. 
Occurring in fleshy and gouty persons, these conditions find their 
most fertile field. 

Diagnosis. — The recognition of a simple erythema intertrigo is a 
matter of no difficulty, if regard be had to the exciting and aggra- 
vating causes enumerated above, and to the special localities where 
such hyperemia generally originates. If an eczema or dermatitis 
supervene, the fact will appear from increased subjective sensation 
(usually a severe itching), from an infiltration of the affected integu- 
ment, and from the appearance of those lesions and discharges which 
are significant of these forms of inflammation of the skin. 

The special sites of preference of an intertrigo are those also of the 
disease named by Hebra " eczema marginatum," or riug-worm as it 
occurs upon the parts of the thighs covered by the " reinforced " patch 
in the trowsers of the cavalryman. The disease is properly named, 
tinea circinata cruris, though it is found also about the axillae, but- 
tocks, and groins of both sexes. Here the disorder is, however, of 
the exudative type, and, moreover, is distinguished by a characteristic 
" festooning" of the elevated border marking the advancing limit of 
the disease. The microscope, by revealing the existence of a fungus, 
will, of course, put an end to any doubt. In intertrigo the most 
marked evidence of disease is to be distinguished in the deeper parts 
of the cleft between the two adjacent skin surfaces, while in tinea 
circinata cruris the growth of the parasite is most active at the ad- 
vancing border of the patch, which is, moreover, perceptibly elevated 
above the sound skin. 

Treatment. — Erythema intertrigo is an exceedingly common affec- 
tion of the skin and occasionally proves of great annoyance to those 
suffering from it. The skill of the young practitioner is often tested 



168 DISEASES OF THE SKIN. 

early in his professional career by his management of just such cases ; 
and not a little may depend upon the success with which he may A be 
rewarded. 

The affected surfaces should be gently cleansed by ablution with 
soap and warm water, aud the offensive odor of the secretions reme- 
died by the addition to the water of a weak solution of carbolic acid, 
or the dilute liquor sodse chlorinatse. The parts are then to be care- 
fully dried with a freshly lauudered towel or soft handkerchief, and 
afterward oue of the dusting powders very thoroughly applied. To 
be of service, these must be quite impalpable, aud, if compouuded by 
a druggist, be sifted through millers' fine silk boltiug-cloth. The 
articles chiefly used for this purpose are: bismuth, starch, ziuc 
oxide, French chalk, lycopodium, and, when an anti-pruritic effect 
is designed, camphor. Combinations of several of these are at times 
effective. The formula of McCall Anderson is highly esteemed : 



R. Zinci oxid. pulv. ^ss; 16 

Camphorse pulv. ^jss ; 6 

Amylipulv. % j ; 32 

Sig. Anderson's dusting powder. 



M. 



The following is the formula for a dusting powder recommended 
by Klamann •} 

K . Talc, venet. pulv. ^v; 20 i 

Acid, salicyl. gr. iij ; 1 2 

Magnes. ust. subtil, pulv. 3Jss; 5j M. 

Sig. Dusting powder. 

The "Oswego gloss starch" and the "corn-starch farina" sold by 
most of the green-grocers in this country, are finely bolted, aud answer 
well alone, or in combination with some of the other articles named. 
The chief objection to the starch-containing powders is their tendency 
to form "cakes" or rolls when wetted with sweat, these masses further 
irritating the tender surface of the skin. Such an objection does not 
apply to lycopodium, which not only under the microscope exhibits 
no salient angles, but on account of the oil it contains is not miscible 
with water. 2 

The affected surfaces of the skin must also be separated in order to 
prevent further friction. A thin strip of lint, antiseptic cotton, 
or medicated wool, may be used for this purpose ; and must be 
pushed well up to the deeper portions of the cleft where the secretion 
chiefly forms. Occasionally, it will be found useful to anoint this 
absorbent layer with cold cream or vaseline. Where an astringent 
effect is desired, the lycopodium or other dusting powder may be com- 
pounded with tannin, alum, or similar substances. The list of lotions 
may be also at times consulted with advantage. Thus, cologne water, 
weak spirit lotions, tannin, and aromatic wine, or carbonate of mag- 
nesium, may each be serviceable. Lastly, the carron oil (equal parts 

1 Hebam. Kalend., Obstet. Gazette, March, 1882. 

2 Unna's salve muslins and pastes will be found effectual and neat applications, in many forms 
of intertrigo. 



ERYTHEMA MULTIFORME. 169 

of lime-water and linseed-oil), spread thickly upon linen, will possibly 
give more relief than the other articles named; the chief objection to 
it being the consequent soiling of the patient's clothing. 



Erythema Multiforme. 

Statistical frequency in America, 1.021. 

Erythema Multiforme is an exudative disease of the skin, in which appear flat 
or elevated lesions of an erythematous type in various forms, the exanthem 
being at times symptomatic of constitutional derangement. 

Symptoms. — In this affection, which is usually of symmetrical de- 
velopment, erythematous maculae, flattened papulae, and even large 
flat nodosities, very rarely vesicles, occur, usually upon portions of 
the extremities, the forearms, the legs, and the dorsum of the hands 
and feet. The eruption which is much more generally recognized in 
clearly defined patches, usually commences with pin-head to finger- 
nail sized macules of a darkish-red shade, losing their color under 
the pressure of the finger, which in the course of some hours exhibit 
tumefaction in various degrees, producing thus the papules, tubercles, 
and nodes already described. The disease may persist for but a few 
days, but in severer grades it lasts for several weeks. In the height 
of the exudative process there is usually an efflux of the coloring 
matter of the blood into the skin which is the site of the several 
lesions ; and thus are produced the singular shades of reddish-black, 
purple and red, blue and red, yellow and orange, which are so char- 
acteristic of simple bruises of the extremities wheu the injury has 
been sufficient to cause extravasation of blood. The lesions occur in 
various shapes, sizes, and shades, and a number of names have been 
used to designate their several appearances, which require explanation, 
though they are without any practical value. 

Erythema Annulare (or Circinatum) is characterized by cen- 
tral paling of color and peripheral extension of the erythematous 
patch, in the form of a ring, 

Erythema Figuratum occurs in gyrations formed by coalescence 
of two or more annular circles. 

Erythema Iris (Herpes Iris) is the result of successive new ery- 
thematous centric colorations, by which at times several differently 
shaded concentric rings are formed. 

This variety of multiform erythema often occurs without other mani- 
festations of the same disease in the patient exhibiting its lesions. 
It is not rarely observed in a single patch on the back of one hand. 
There may be a central vesicle or bulla with a series of concentric 
rings about it, the latter constituted either of discrete or confluent 
vesicles or bullae. There is always a narrow and purplish shaded 



170 DISEASES OF THE SKIN. 

areola about the fully disteuded or flattened and depressed central 
lesion, and the " iris " effect is produced by the contrast of the 
whitish fluid in the chambers with the color of the pinkish zone. 
Patches may symmetrically develop on both hands or the fingers of 
the two hands, and finally, desiccating complete a cycle of three or 
four weeks' duration. Variations occur by reason of effusion of fluid 
until large bullae form, which may coalesce or be filled with blood ; 
while, according to Crocker, hematuria may result with severe in- 
volvement of the mucous membrane of the lips, tongue, soft palate, 
and other parts of the mouth, ulceration rapidly ensuing. 

Cases with these complications should be really classified with the 
grave forms of pemphigus, to which they properly belong. 

Under the title Herpes Iris of Bateman, French authors de- 
scribe the Hydroa Vesiculeux of Bazin. In this affection there 
first appear reddish papules, in the centre of which a faintly devel- 
oped vesicle forms, which desiccates and forms thus a delicate crust. 
New well-distended or abortive vesicular lesions form peripherally 
in successive reddish, bluish, or purplish rings about the central 
crust, with an erythematous zone about the patch. In this disorder, 
also, may succeed generalization of the eruption, involvement of the 
mucous surfaces (including severe oral and labial lesions) and grave 
symptoms of a general character. 

Erythema Marginatum is that form in which a distinctly ele- 
vated and defined marginal band is left as the sequel of an erythe- 
matous patch. 

Erythema Nodosum (Dermatitis Contusiformis : Fr., Erytheme 
Noueux) is regarded by several authors as a distinct affection. In it 
the characteristic lesions are of the dimensions of semi-globular pea 
to fist-sized tumors, pale red to livid blue in color, tender upon 
pressure, exhibiting in their involution the variegations of hue 
already described. They occur at times not only in the localities 
named above, but also upon the trunk and face. Though occasion- 
ally becoming so soft to the touch that fluctuation may seem to be 
present, they never terminate by suppuration. 

They occur most often in youth, in girls more often than in boys, 
with acute or subacute symptoms, frequently with rheumatoid pains 
and febrile temperatures. The oval or roundish erythematous or 
empurpled nodes, varying in size from a small nut to a pigeon's egg, 
are most often seen on the lower limbs, though they appear also on 
the thighs, the buttocks, and the forearms. They are usually tender 
on pressure, and often painful. They may disappear in a fortnight 
but occasionally observe a stadium of six weeks' duration, forming 
and disappearing in crops. The petechial appearance of the spots 
where they have existed is that of the characteristic " black-and- 
blue " mark. By some authors the disease is recorded as associated 
with tuberculosis, an observation probably due to the fact that it 
appears so often among the poorly nourished and ill housed. It 



ERYTHEMA MULTIFORME. 171 

unquestionably occurs most frequently in the spring and autumn. 
Other causes cited are malarial chills, temperature changes, rheuma- 
tism, gout (rare in young adults), arthritis, endocarditis, urethral 
irritation (blennorrhagic, instrumental, medicamentous) ingesta, 
alcoholic excesses, and dentition (?). 

Erythema Papulatum (or Papulosum) and Erythema 
Tuberculatum (or Tuberculosum) are those forms in which 
occur lesions respectively of a papular or tubercular type. 

Erythema Urticatum is that form in which there is severe 
itching and, as a result, scratching of the lesions, with crusts of dark 
dried blood at the summit of each. This crust is surrounded by the 
light red or bluish-red, flattened or elevated patch characteristic of 
the disease. 

Erythema Vesiculosum and Erythema Bullosum are rare 
and exceptional forms where the exudation is sufficient to raise the 
horny layer of the epidermis into larger or smaller serum-containing 
chambers. These may be, as regards the erythematous patch, of 
central or peripheral situation ; and may crown the summit of papule 
or tubercle. The fluid is usually removed by absorption, and is 
rarely set free by rupture of the vesicle or bleb. 

Robinson 1 describes definitely an Erythema Diphtheriticum, 
which is a rash of septic diphtheria. The early eruption is a diffuse 
erythema of the skin of the chest or of the belly, light red to pale 
red, mottled, scarlatiniform, or punctate, non-pruritic, disappearing 
under pressure, unaccompanied by fever, and vanishing in one or 
two days. 

The rash of septic diphtheria occurs only after several days of the 
disease, and is a limited or generalized erythema. It begins as pin- 
head or larger sized erythematous maculae, each of which spreads at 
the periphery and pales in the centre, by which process rings are 
formed. The latter increase until a diameter of several inches is 
attained. While these erythematous rings with clearing centre and 
reel, elevated rims are enlarging new spots continue to form, until 
the eruption has all the features of a multiform erythema. Gyrate 
and figured forms result from coalescence of lesions. Occasionally, 
the centre of a ring is cyanotic. The eruption does not itch. In 
fatal cases it persists until death. 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For descriptions of these the reader 
is referred to the chapters devoted to dermatitis medicamentosa and 

1 Journ. of Cutan. and Ven. Dis., 18S3, p. 83. 



172 DISEASES OF THE SKIN. 

dermatitis venenata. Quinine, the iodine and bromine compounds, 
arsenic, belladonna, chloral, salicylic acid, and other substances, are 
often responsible for these symptoms. 

The name, multiforme, given to this disease by Hebra, is justified 
by the singular diversity of lesions which it displays. These are 
remarkable not merely for their variety but for their occurrence in 
such variety both simultaneously and successively, and for their 
rapid change from one type to another. 

The subjective symptoms, save in the urticarial form of the dis- 
ease, are usually of a trifling character. The slight sense of heat and 
burning awakened by the lesions is altogether out of proportion to 
the extent of development of the latter. 

The symptoms, however, indicative of a general disturbance of 
the system may be of a marked character. General malaise, fever, 
inappetence, pharyngeal inflammation, chills, severe gastro-intestinal 
disorder, rheumatoid involvement of the articulations, and even 
organic changes in the heart (valves, endocardium, and pericardium), 
lungs, and kidneys (Kaposi), have all been noted as coincident or 
causative phenomena. In many of these cases it is clear that the 
exauthem belongs to the list of symptomatic erythemata, aud is of 
insignificance in comparison with the grave general condition. It 
may thus be the precursor of typhoid fever, malaria, severe articular 
rheumatism, or become even an abortive expression of these disor- 
ders. With these exceptions, however, the prognosis is in general 
quite favorable, as the disease may terminate in a few days, and 
rarely exceeds a month in duration. 

Occasionally the mucous membranes are affected to a disagreeable 
or even painful extent. Thus a sudden tumefaction of the uvula 
may supervene upon the cutaneous symptoms, even in cases suffi- 
cient to impede respiration ; or the lining membrane of the larynx 
be involved, and the resulting aphonia in various degrees persist for 
two or three days. 

Etiology. — The affection is more common in the spring aud 
autumn ; it occurs in the young or in the early periods of adult life; 
the papular and tubercular forms are more commou in men, aud the 
nodose forms in women ; in mauy cases it occurs in those who are 
affected with rheumatism. There can be but little doubt that its 
etiology includes a list of varying and widely differing causes. The 
author has seen severe manifestations of the disease in a young 
woman with extensive ulceration of the cervix uteri. Tilbury Fox 
noticed its frequency in young servants brought to town from the 
country. It is not rare in young female immigrants who have re- 
cently made a " steerage " passage to this country. 

Pathology. — Erythema multiforme is essentially an hyperemia of 
the integument which, under certain obscure influences, advances 
more or less rapidly to the stage of a mild grade of inflammation 
with consequent exudation. If, with Landois and Lewin, it be 
accepted that the process is the result of vasomotor nerve influence, 
it cannot be determined whether these nerves are irritated at points 



ERYTHEMA MULTIFORME. 173 

of origin or distribution. In the case of erythema nodosum, Hebra 
advances what he admits to be an hypothesis, in saying that the 
morbid process is essentially an inflammation of the lymphatic ves- 
sels. In some cases it is evident that there is extravasation of blood 
from the vessels into the skin of the affected parts. 

Leloir 1 discovered in the papules, tubercles, and bulla? of the ery- 
themata, only the phenomena of hyperemia and exudation limited 
to the corinm and subcutaneous tissue; and Yillemin 2 simply con- 
firms these facts. 

Crocker, examining a patch of erythema tuberculatum recognized 
merely a cell effusion in the upper portion of the corium extending 
sparsely below, and then along the ducts and follicles chiefly. There 
was slight rete proliferation. 

Diagnosis. — Erythema multiforme is always to be carefully dis- 
tinguished from the traumatisms producing bruises, especially upon 
the lower extremities. This is a point which may have an interest- 
ing bearing upon certain medico-legal questions, especially in the 
case of young children. 3 The tendency of the disease here consid- 
ered to symmetrical arrangement upon the two sides of the body ; 
the occurrence of lesions evidently dating from several periods, 
where successive crops appear, and the absence of all history of ex- 
ternal injury, will usually suffice to establish a diagnosis. Among 
the precocious affections of the subcutaneous connective tissue in 
syphilis, Mauriac has described a lesion resembling somewhat the 
symptoms of erythema nodosum ; but in such cases, and especially 
in women, mucous patches of the vulva, anus, or mouth, with coin- 
cident adenopathy, would point to the real nature of the disease. 
Syphilitic nodes and gummata are distinguished from the lesions of 
the nodose forms of erythema by the pain attending the former, 
their fewness, their untinted overlying integument sore when actu- 
ally softening and near the point of disintegration, their obviously 
subcutaneous site, and the usual concomitant symptoms of late lues. 

The chief points by which a diagnosis of the erythemata in gen- 
eral is established are : the recognition of the vivid coloring of most 
of the lesions ; the pigmentation following those situated on the 
lower limbs ; their association with rheumatism or rheumatoid pains ; 
their febrile phenomena ; their symmetry as a rule ; and the accompa- 
nying malaise. The wheals of urticaria are smaller, more whitish 
centrally, more closely packed together, less symmetrical, rarely 
grouped, and, as a rule, decidedly more acute. Cases difficult to 
assign to either disease are common, and an error in either direction 
is not serious. Rubella (German measles) is to be distinguished by 
its adenopathy, its pharyngeal symptoms, and its flattish spots. In 
eczema erythematosum there is less definition of each patch, and the 
redness is commonly diffuse; papular forms of eczema are usually 

i Bull, de la Soc. Anat, 1884, p. 294. 2 Gaz. Hebdom., 1886, Xos. 22, 23. 

3 Since this paragraph was written, the author, in conjunction with a number of other phy- 
sicians, was summoned as a witness in a case where both parents of a lad who exhibited the 
lesions of polymorphous erythema, and who died suddenly, were ctiarged with beating their 
child to death. They were exonerated on the basis of the evidence of the experts. 



174 DISEASES OF THE SKIN. 

commingled with other readily distinguished symptoms of that dis- 
ease. 

Lastly, the iodide of potassium and a few other drugs adminis- 
tered internally, are capable of producing almost every one of the 
lesions described above. In the erythemata for which that remedy 
has been administered with the production of skin symptoms, the 
confusion is erroneous. 

Treatment. — As the disease under consideration progresses natur- 
ally to a favorable termination within the course of a few weeks, the 
duty of the physician is usually limited to the question of diagnosis 
merely. He should remember that the larger lesions seen in ery- 
thema nodosum never suppurate ; and thus be not tempted to open 
them with a lancet. Local treatment is rarely called for ; and in 
any case should be restricted to the application of hot or cold water, 
as found most grateful to the patient, with possibly the use of a weak 
lead lotion. Internally such medication should be employed as is 
indicated by the general condition of the patient. Iron, quinine, 
strychnia, and dilute hydrochloric acid will be found beneficial in 
many cases. Constipation and indigestion are to be corrected by 
appropriate measures. When the disorder is evidently purely symp- 
tomatic the internal treatment is to be directed to the general con- 
dition present. In rheumatic cases, the indications for such treat- 
ment are clear. When the erythema produces extensive oedema of 
the uvula, incisions may be requisite to prevent dyspnoea and dys- 
phagia. 

Prognosis. — It will be gathered from what has preceded, that the 
prognosis is always favorable. The fatal cases reported are usually 
those where the result was due to grave constitutional conditions, 
and where the erythema multiforme was an insignificant feature of 
the malady. The disease may relapse in susceptible individuals at 
those periods of the year when it is most frequently observed. 



Urticaria. 

Lat. itrtica, the nettle. 

(Hives, Nettle-rash. Fu., TJrticaire ; Ger., Nesselsuch, 
Nesselfieber.) 

Statistical frequency in America, 2.47. 

Urticaria is an exudative affection of the skin in which appear ephemeral, 

whitish, or rosy-tinted wheals surrounded by a reddish areola, giving rise to 

an intense pruritus. 

Symptoms. — This disorder may be ushered in by constitutional 
symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
symptoms lasting for a few hours or even for a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the surface, which 



URTICARIA. 175 

frequently disappear with equal rapidity, leaving behind no traces of 
their existence save a slight and transitory hyperemia of the affected 
spot. The lesions may be as small as a finger-nail or a coffee-bean, 
and are usually of this size ; but in certain rare instances " giant 
wheals " are seen, large tomato-sized projections or flat elevations of 
broad areas of the integument, covering the greater part of the belly 
or the buttock. In color, they are either rosy-red or whitish ; and 
are usually surrounded by an hypergemic areola. They may be 
isolated and few ; or numerous and closely packed together ; may 
even coalesce so that individual lesions are scarcely recognizable. 
They are usually firm and semi-solid to the touch. Rarely the horny 
layer of the skin is raised in fluid-containing lesions by the sudden 
effusion of serum beneath. In contour, they are roundish or oval- 
shaped ; but a variety of curious outlines may result from the irregu- 
larity of their development. Concentric circles, lines, bands, and 
even figures, are in this way produced. The finger-nail drawn across 
the unaffected portions of the skin, in a patient with urticaria, will 
often produce a linear wheal of extent corresponding to the line of 
irritation. It is said that in this way the so-called " medium " with 
a sensitive skin exhibits written characters upon the surface of his 
body. 

The subjective sensations induced by these lesions are distressing 
in various degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensations are thus engendered. The efforts of 
the patient to secure relief by scratching, not only serve still further 
to develop the eruption, but to irritate, tear, and otherwise wound 
those lesions already in full evolution. In this way the serous 
effusions are produced at the summits of the wheal ; and in this way, 
also, lesions really transitory in their course may be changed to 
more persistent, deeply colored, flat, lenticular papules. Where the 
skin is delicate and thin, as that of the lids and prepuce, considerable 
oedemra may result. 

All parts of the body may become affected, and this irrespective of 
age and sex, though children are particularly liable to the disease. 
There are few very young children with skins unwashed for an entire 
month, who will not exhibit urticarial symptoms if there be an 
added irritation of the surface. 

The lesions may be numerically few, or so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they may recur frequently from apparently insignificant 
causes, or even become chronic. In many cases trivial, the disease 
may become so aggravated as to make the largest demands upon the 
skill of the physician. 

The rapidity of appearance and disappearance of the lesions visible 
upon the skin is a characteristic feature of the disease. In some 
instances but a few moments are required after the operation of an 
efficient cause, to develop a large number of closely packed wheals 
upon the skin. Even while these are under inspection, it can be 



176 



DISEASES OF THE SKIN. 



noted that there is a change in individual lesions, some fading or 
completely disappearing, while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus U. Annularis occurs in rings ; U. Figurata, in gyrations from 
union of several lesions or patches of lesions ; U. Vesiculosa and 
U. Bullosa, where there is a vesicular or bullous development at the 
summit of the lesion; and U. Papulosa (or Lichen Urticatus), where 
there is a combination of the features of the wheal and the papule, 
the lesions being usually rape-seed to coffee-bean in size, and covered 

with blood crusts where their 
fig. 40. apices have been torn in scratch- 

ing; U. Tuberosa, where " giant" 
wheals occur, some attaining the 
size of a hen's egg ; U. Hemor- 
rhagica (Purpura Urticata), where 
the urticarial element is developed 
in a lesion produced by cutaneous 
haemorrhage ; and U. Evanida, or 
Perstans, where there is respec- 
tively a rapid or slow process 
of involution in the character- 
istic symptoms. 

Urticaria Pigmentosa 
(Xanthelasmoidea of Fox). — 
This disorder, once regarded as an 
affection of great rarity, has now 
been observed in a sufficient num- 
ber of cases in almost all of the 
larger centres of population. The 
disease is one characterized by the 
occurrence in early infancy, some- 
times but a few hours or weeks 
after birth, of elevated rosy or 
reddish wheals which are suc- 
ceeded later by flattish or slightly 
elevated light or dark-brownish or 
buff-colored macules. There are 
three tolerably distinct types of 
the affection : those exhibiting 
plane lesions with equally flat- 
tened maculations ; those with 
tubercular, nodular, or variously sized and shaped wheals ; and mixed 
varieties, the latter being most common. The mingling of a factitious 
urticaria with lesions long existing and long maculated is not rare. 
Cases are sometimes divided into those accompanied by itching and 
those not so characterized ; but it appears that these differences are 
due to accidental rather than essential causes. The eruption, which 




Urticaria pigmentosa. (From a photograph 
of one of the author's patients.) 



URTICARIA. 177 

may first appear as late as the third year, commonly displays itself 
first on the neck and shoulders and spreads rapidly to the head and 
extremities, eventually invading the entire surface — in well-marked 
eases even including the mucous surfaces. The lesions are at first 
of the usual urticarial type, with delicate zone, but soon lose their 
distinct contour and elevation, and become flatter and pigmented, 
the color in pronounced cases being a distinct yellow, deepening to 
a decided coffee-and-milk hue. After isolated tubercles once acquire 
the deeper tint, they may persist for years ; may return in crops ; 
may even be at times commingled with bullse which desiccate in 
crusts ; may form plaques of infiltration ; may be covered at times 
with an erythematous blush due to hyperemia of parts long affected ; 
and when itching is intense may exhibit the general signs of the 
scratched skin. In some of the reported cases whitish instead of 
pigmented spots were left after involution in a smooth or wrinkled 
and scar-like skin. 

Etiology. — The cause is unknown. The sexes are nearly equally 
represented among patients. 

Pathology. — Sections of tubercles have been made by numerous 
observers, including Unna, Raymond, Pick, and Thin. It is clear 
that some effusion occurs in the corium with cell infiltration and 
small haemorrhages. The disorder is unquestionably an angeio-neu- 
rosis due to special changes of the vasomotor centres. According to 
Brocq, the predominant elements of the infiltration are the mastzellen. 

Diagnosis. — It is to be distinguished from the slight pigmentation 
left after well-marked urticaria of later years by the beginning of 
the disease in infancy and by the persistent buff- colored tubercles. 
Xanthoma in all its forms is readily distinguished by its persistence 
in special regions, the eyelids, for example ; by its first appearance at 
a later period of life ; and by its characteristic chamois-leather-yellow 
shade. 

Treatment. — No treatment has been hitherto so successful as to 
justify its recommendation. The author has had best results in 
stimulating rather than soothing baths, at a later period of life than 
the first six months. After such stimulation with salt and water and 
alcohol and water, a boric acid dusting powder is always applied. 

Angeio-neurotic OEdema (Acute Circumscribed (Edema, Acute 
Idiopathic (Edema, Periodic Swelling, Acute Non-inflammatory 
(Edema, Giant Swelling) is characterized by the appearance on various 
parts of the body, particularly the face, extremities, and throat, chiefly 
of male subjects who may have inherited a tendency to this or a similar 
disorder, of suddenly evolved swellings of the skin, usually dull red in 
hue, contrasting vividly with the color of the surrounding integument, 
and disappearing in the course of a few hours. They are commonly 
the seat of disagreeable sensations of fullness, burning, throbbing, 
or scalding ; aud if the swelling chance to obstruct a mucous tract 
(nasal, pharyngeal, laryngeal, etc.), there are symptoms of a distress- 
ing character, due to the transitory occlusion. The tumefactions are 

12 



178 DISEASES OF THE SKIN. 

so large as to involve an entire organ or limb. Collins/ who has 
drawn an excellent portrait of this disorder, believes it to be at least 
closely allied to, if not identical with, urticaria tuberosa, or giant 
urticaria, and that its seat is in the vessels, vascular and lymphatic, 
traversing the corium ; the swelling being the result of disturbance 
of the sympathetic nervous system. It is to be distinguished from 
the " blue oedema" of hysteria (Sydenham) and from the " white 
oedematous swellings " of the same disease as observed by Charcot. 
This disorder is also described in this work in connection with other 
oedematous affections of the skin. 

Baker 2 reported a case of Urticaria Tuberosa characterized by the 
presence of persistent, yellowish-red tubercles in various parts of the 
body which proceeded to ulceration. The parts most affected were 
the knuckles, elbows, and ears. These tubercles are said to have 
begun in a manner similar to that which characterizes the onset of 
evanescent urticarial wheals and tubercles. A somewhat similar case 
was observed by McCall Anderson. 3 

Urticaria, like erythema, may be either idiopathic or symptomatic ; 
and in either the urticarial conditions may underlie or be superim- 
posed upon almost every elementary lesion noted in the integument. 
Its lesion may complicate (or be complicated by) the macule, papule, 
tubercle, vesicle, bulla, and pustule. It may spring from an excoria- 
tion, or result in a fissure. It is common is traumatisms, and is a 
prominent symptom in the skin bitten by insects, reptiles, and the 
domestic animals. 

Etiology. — Idiopathic urticaria always results from the action of 
external irritants. The enumeration of these would require a recital 
of all the external agencies which are capable of irritating the skin. 
Prominent among them are the bites and stings of mosquitoes, lice, 
fleas, bed-bugs, flies, gnats, wasps, caterpillars, and bees. Contact 
with certain species of the jelly-fish is also effective. The wounds 
thus inflicted usually excite a stinging or burning sensation, by 
which the patient is excited to rub or scratch the part. Then 
a wheal is rapidly formed at the site of the injury, and the irritation 
thus set up is conveyed to other parts of the skin in the vicinity, 
so that, especially in children, a single traumatism by an insect may 
excite an urticaria covering a much larger area. Many medicaments 
operate similarly, and it should be added that some of them, though 
applied externally without toxic effect to the mass of men, may pro- 
duce urticaria in exceptional cases. Thus a common flaxseed poul- 
tice when made to cover but a small portion of the body has pro- 
duced violent symptoms of the disease under consideration. The 
irritant action of the nettle (U. urens and U. dioica) has given the 
malady its name. Climatic influences, more particularly those in 
which the surface of the body is exposed to cold air, are very efficient 

1 Amer. Journ. of the Med. Sci., Nov., 1892. 

2 Lancet, August, 1881, p. 153. 3 Brit. Med. Journ., December 8, 1883. 



URTICARIA. 179 

in the production of urticaria, as also of bronchial asthma, with the 
symptoms of which the disease under consideration may often coexist 
or alternate, in the case of adults. Mechanical violence, the applica- 
tion of leeches to the surface, and surgical traumatisms may also in- 
duce the disease. 

Symptomatic urticaria is chiefly of the variety named by authors, 
ab ingestis, since it most frequently results from medicinal or dietary 
articles taken into the stomach. Of the latter class may be named 
eggs, cheese, pork, sausage, coffee, tea, cocoa, and confectionery ; 
crabs, lobsters, clams, caviar, and several species of fish-roe, oysters, 
and fish generally ; strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, and raspberries ; 
canned fruits, meats, and vegetables ; oatmeal, peas, beans, onions, 
garlic, and "corn;" pickles, sauces, honey, mushrooms, pastry, 
salads, and spinach. Vinegar, champagne, beer, and alcoholic bever- 
ages in general are capable of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may 
be named the balsams, the turpentines, quinine, glycerin, chloral, 
valerian, arsenic, hyoscyamus, cinchonidia, salicylic acid and the 
salicylates, senna, santonine, and opium and its alkaloids. 

In the case of children and infants, a severe urticarial efflorescence 
may be provoked by worms, or by any undigested morsel of food, or 
indigestible material of any sort which may have been passed into 
the stomach. Thus a bit of orange-peel, or fragment of potato-par- 
ing, or the skin of grapes, may be discovered to lie at the root of the 
trouble. In the case of adults also who have suffered from repeated 
attacks of urticaria, and have a fully developed sensitiveness of the 
gastro-intestinal tract, almost any unusual alimentary substance, if 
ingested, may induce a return of the disagreeable symptoms. 

It must be borne in mind that this undue sensitiveness to the effect 
of ingesta or external irritants is often an idiosyncrasy peculiar to the 
individual either on special occasions or at all times, and that, given 
this susceptibility, the effect is often great with a relatively insignifi- 
cant etiological factor. Thus one may see cases in which a teaspoonful 
of beer, one grain of quinine, the smallest fragment of cheese, and 
but a single strawberry will not only induce an urticarial rash of 
such extent as to cover the greater part of the surface of the body, 
but will do the same on every occasion when the articles named 
are swallowed in the quantities given. This, it is important to re- 
member, is in general characteristic of the medicament on s eruptions. 
The a priori reasoning, that the greater the quantity of the toxic 
agent applied or swallowed, the graver the effect, may lead to gross 
errors. It should always be remembered, in seeking the explanation 
for an urticarial rash, that the smallest amounts of apparently inno- 
cent substances may be responsible for the largest annoyance. 

Other causes of urticaria may be cited, such as moral emotions 
(fear, shame, anger) ; pulmonary diseases, especially asthma • gastro- 
intestinal disorders, where ingesta play no part; intestinal parasites; 
malaria ; the exanthematous fevers, particularly in their prodromal 



180 DISEASES OF THE SKIN. 

stages ; disorders of the uterus, kidneys, and nervous centres ; preg- 
nancy, dentition, and the irregularities attending the menopause; and, 
lastly, the following special diseases : asthma, pemphigus, prurigo 
(of Hebra), rheumatism, and purpura. 

Pathology. — The wheal of urticaria is produced by an interchange 
of play between bloodvessels, muscles, nerves, and tissue, under the 
operation of a principle which the French term the choc en retour. 
There is, first, most probably under the influence of the vasomotor 
nerves, a clonic spasm of the capillaries in a limited area of the 
derma, by which an acute oedema is produced with some serous exu- 
dation. The rapidity with which this occurs is greater than that 
with which the tissues of the vicinage can accommodate themselves 
to it, either by imbibition or more diffuse tumefaction, and there 
results a counter pressure upon the affected capillaries, by which their 
lumen is still further restricted. As the wheal is not a purely fluid- 
containing nor yet an entirely solid lesion, but is semi-fluid in con- 
sistency, the mechanical pressure is greatest at the centre and least at 
the periphery. Thus is explained the white and relatively bloodless 
appearance of the centre of certain wheals, and their rosy or reddened 
outer border. It is confirmed also by the fact that generally the 
most acute lesions, those springing into view most rapidly, are chiefly 
characterized by this wiiitened centre, while those more indolent or 
even chronic in their career, have been less subject to the inter-play 
of the forces described above, permit of more general vascular injec- 
tion, and have a light crimson or even at times a dull red centre. 
Wheals have been excised and examined microscopically by Neumann, 
Vidal, Poncet, and others, with the result of discovering merely evi- 
dences of dilatation and engorgement of blood and lymph vessels and 
infiltration. According to the last-named author, the lymphatic 
vessels are also choked with " lymph clots." R0I16 1 explains the 
occurrence of the wheal by supposing that certain seusitive nerve- 
fibres of the skin possess also a vasomotor function. 

The process described, occurring as an epiphenomenon after the 
traumatisms or other cutaneous lesions enumerated above, merely 
adds its characteristic symptoms to those previously apparent. 

Diagnosis. — The diagnosis of typical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which con- 
fusion may arise. The chief points to be remembered are : the rapidity 
of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action of the animal parasites 
and insects not parasitic should not be overlooked, and the rash be 
closely examined for the minute wounds inflicted in this way, often 
covered with a minute pin-point to pin -head sized dried " blood- 
scale." The various forms of erythema papulatum, tuberculatum, 
and nodosum are liable to be mistaken for urticaria ; but this is in 
many cases inevitable, as the intermediate forms between the two 

1 Maryland Med. Journ., May 15, 1881. 



URTICARIA. 181 

disorders are with difficulty assigned to either category. Absence of 
marked subjective sensations and persistence of lesions would gen- 
erally imply the existence of an erythema, while marked prevalence 
of these symptoms would properly decide in favor of urticarial 
disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capriciously 
selected hours, who repeatedly and vainly endeavors to exhibit the 
lesions as they appear upon the skin. Being examined on occasions, 
scarcely a trace of cutaneous disorder is manifest. Here the practi- 
tioner has practically to decide upon the character of an eruption he 
never sees. The task is rarely a difficult one. No other than the 
urticarial eruption behaves in this fashion. Occasionally the physi- 
cian will discover delicate, rosy, or deeper stained mottlings of the 
surface where the wheals have been but are not. At times also he 
will succeed, on the flexor aspect of the forearm, or in some situation 
where the skin is equally delicate, in producing the appearance of one 
or more typical lesions by the aid of his finger-nail in scratching or 
rubbing. These cases are more frequently of the chronic or at least 
relapsing class ; and the victims of the disease may have a char- 
teristic facies, a worn look from loss of sleep or mental emotion. One 
is apt to discover in this class those who are mourning over the death 
of relatives, loss of property, separation from home and friends, and 
those harassed by anxieties. 

The several lesions of erythema are larger than those of urticaria, 
and do not develop from characteristic wheals ; in erythema multi- 
forme the lesions are far more persistent in type and do not provoke 
the characteristic subjective sensations of urticaria ; in erysipelas the 
redness is characteristic aud the swelling more diffuse. 

Treatment. — Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diagnosis. The patient and his 
friends are alarmed by the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder they wait with equanimity for the conclusion which is 
always reached. Fortunately, the unusual, severe, and relapsing 
forms rarely begin with acute symptoms. 

Naturally the first indication to be observed is the removal of the 
cause, and this, if possible, accomplished, the exclusion next of all 
aggravating agencies. The discovery of the cause, at times readily 
effected, is often the most serious problem which is presented. An 
exhaustive and minute examination of the person and history of the 
patient, a study of his food, drink, medicine, regime, clothing, sleep- 
ing apartment, habits, occupations of life, and mental state, are here 
essential. When the disorder is recent, and is an urticaria ab ingestis, 
a brisk emetic or carthartic may rid the stomach or bowels of 
offending matters. This done, it should be borne in mind that an 
idiosyncrasy of the patient may at this moment render the skin 
peculiarly sensitive to the action of other ingesta, and the diet, for a 
few days certainly, should be carefully prescribed. In many cases 



182 DISEASES OF THE SKIN. 

the alkalies are indicated by an acid condition of the stomach, and 
then the preparations of sodium, potassium, and magnesium are use- 
ful. Laxatives, such as rhubarb, magnesia, the cathartic mineral 
waters, and, in the case of children, small doses of castor oil are 
frequently indicated when there is no suspicion of irritating ingesta. 
At other times there is marked atony of the digestive organs, when 
the mineral acids, the bitters, and the ferruginous tonics may be 
needed. Again, lactopeptine, pepsine, or the subcarbonate or the sub- 
nitrate of bismuth may be exhibited with advantage for the relief 
of the indigestion which may be the prominent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in drachm (4.) doses three times daily in 
sweetened water (Da Costa) ; copaiba ; strychnia (Gruibout) ; the 
arseniate of sodium, employed by Blondeau, in doses from one- 
thirtieth (0.002) to one-fiftieth (0.0013) of a grain ; the fluid extract 
of ergot in half-drachm (2.) doses (Morrow) ; the sulphate of atropia, 
given by Schwimmer in doses of one-sixtieth (0.001) of a grain j 
and the salicylate of sodium in scruple (1.33) doses. The last- 
named drug has been highly praised by a number of writers. It is 
often given in one grain (0.06) doses every hour. Pilocarpine, or 
the fluid extract of jaborandi, is known to produce at times a pow- 
erful effect in relieving surface congestions of the skin by means of 
the excessive hyperidrosis which it occasions, and in proportion to 
which it may become dangerous. 

Schwimmer endorses the following formula for this affection : 



R . Atropise sulph. gr. £ ; 

SSI »*■: 

Gum. tragacanth. q. s. ; 
Ft. pil. No. xx. 



01 

M. 



The treatment of a symptomatic urticaria should have regard also 
to that disorder of the viscera or general system to which the 
cutaneous symptoms may be attributed. Gout, as a not infrequent 
cause of the disease, should not be forgotten in advising treatment. 
The uterine complaint of a woman may require appropriate treat- 
ment, as also the diabetes of the patient with an affection of the kid- 
neys. Quinine is, of course, indicated in periodical attacks, but its 
action in exceptional cases as a direct cause of urticaria should not 
be forgotten. The same, to a greater extent, is true of arsenic, the 
bromide and iodide of potassium, hydrate of chloral, and gelsemium. 
The larger number of patients are best treated without the employ- 
ment of these drugs. 

In the local treatment of urticaria, which is chiefly intended to 
assuage the disagreeable sensations experienced in the skin, the 
greatest diversity exists in the methods employed. This is to be 
largely explained by the fact that a similar difference is to be noted 
in the relief experienced by different patients after the application of 
the same medicinal agent. Thus cold and hot water baths, baths 
medicated by marine salt, aromatic vinegar, alcohol, cologne, camphor, 



URTICARIA. 183 

the alkalies, and sulphuric ether ; compresses dipped in such solutions 
and laid over the part affected ; douches and vapor baths will, auy 
of them, in the case of some individuals produce a marked allevia- 
tion of symptoms, and in others be either inoperative or actually 
serve to aggravate the symptoms in the highest degree. Hebra 
asserted that several of the baths named above are quite useless, 
while Kaposi recommends cold lotions medicated with aromatic 
volatile substances. Fox prefers alcohol, or cologne water to 
which benzoic acid has been added, dabbed over the part, and 
permitted to evaporate. Hillairet and Gaucher employ in a simi- 
lar way a solution consisting of one-third of ether and two of warm 
water. 

The alkaline bath should contain the carbonate of sodium, the bi- 
borate of sodium, alum, or the bicarbonate of potassium, either singly 
or in combination in the strength of about six ounces (1 92.) of the 
salt to thirty gallons of water. One or two ounces (32.-64.) of the 
sulphuret of potassium may be substituted for these. The water is 
made demulcent by the addition of starch or gelatin, or by immers- 
ing in it a bag of muslin containing bran. When it is desired to 
employ the acid bath, half an ounce (16.) of either the muriatic or 
nitric acid is added to the quantity of water given above. The bath 
of this size may also be medicated with one drachm (4.) of corrosive 
sublimate ; or this drug may be used as a lotion in the strength of 
from one-fourth (0.0016) to one-half (0.0033) a grain to the pint. 
Carbolic, benzoic, salicylic, boric, dilute hydrocyanic, and dilute 
nitric acids in weak solution, are also employed with advantage in 
some cases. Other external applications are thymol, carbonate of 
ammonium, bromide of potassium, ether, chloroform, and chloral- 
camphor in the strength of half to one drachm (2.-4.) to the ounce 
(32 ) of ointment. This last is prepared by rubbing together equal 
parts of camphor and chloral till a semi-liquid substance results. It 
is an antipruritic remedy of some value, but will increase the uneasy 
sensations produced, if not largely diluted. 

In other cases the oily or fatty substances will give more prompt 
relief, especially if the eruption has been much irritated by scratching 
and tends to persist. Among them may be named the linimentum 
calcis of the pharmacopoeia, and cold cream to which have been 
added a few drops of the fluid extract of grindelia robusta. 

Mention should also be made here of the dusting powders which 
the reader will find described in the chapters relating to general 
therapeutics and the erythemata. They are the most cleanly of all 
external preparations in urticaria, and are often the only local 
measures required. With internal medication, as each case may sug- 
gest, the practitioner will be careful to note that the clothing of the 
patient is of a character that will not aggravate the eruption, that 
sleep is secured without an excess of bed-covering, and that places 
where the temperature is for any reason elevated are carefully avoided, 
such as the proximity to a fire-place or drop-light, the opera-house, 
the kitchen, etc. 



184 DISEASES OF THE SKIN. 

Among the Germans, sulphur, naphthol, and tar salves are em- 
ployed iu the management of the disease. 

One of the most effective and trustworthy of local applications in 
severe urticaria is a starch solution. The starch is first mixed with 
cold water, and then boiled till the solution is of the consistency of 
thin mucilage. To each pint of this a drachm (4.) of the oxide of zinc, 
and a couple of drachms of glycerin (8.) are added before ebullition 
is completed. When cool, and applied to the surface, this often gives 
prompt relief. The same is true of a thin solution of boiled oatmeal. 

Such is the empirical treatment of urticaria. It will be seen to be 
founded upon no rational method of procedure, and this because the 
very capriciousness of the disease demands and secures relief in one 
instance by a treatment which should be reversed in another. It 
must be admitted that cases occur in which all treatment seems abso- 
lutely valueless, often really injurious to the patient. These cases 
will usually be found to be of the relapsing or chronic type. The 
subjects of this form of disease are often plunged in morbid mental 
states ; dreading by day the exacerbations of the night ; brooding 
over misfortunes experienced or anticipated ; w r orn with loss of sleep ; 
fearful of a generous regime at the table. Here the treatment is 
largely moral, and makes demands upon the tact and courage of the 
physician. Travel, change of climate, variation in the routine of life, 
new social surroundings, are here valuable. The widow must be 
made to lay aside the heavy crape veil beneath which her urticaria 
plays ; the solitary patient must secure a companion capable of 
diverting the nervous attention for a few hours each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at the various mineral springs, 
both in this country and abroad. Thus the Karlsbad, Vichy, Sara- 
toga, and White Sulphur Springs, have all been credited with the 
production of beneficial effects in urticaria. 

Prognosis. — The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest souvenir of the trouble. In the 
case of children, the attack is often at an end in the course of twenty- 
four hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance, and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a more formidable affection than a mild attack of 
syphilis, 

Dermatitis. 

Dermatitis is an affection of the skin characterized by the phenomena of in- 
flammation, including heat, redness, pain, and infiltration, terminating in 
resolution, suppuration, or the occurrence of gangrene. 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under this title, however, are grouped those inflamma- 



DERMATITIS. 185 

tioDs where the result is plainly due to a direct influence exerted 
upon the skin by thermal, chemical, or mechanical agencies. These 
inflammations may be mild or severe. 

The milder forms of dermatitis disappear without leaving behind 
them persistent lesions. The graver forms may terminate in gan- 
grene, or produce death by shock or exhaustion. 

Dermatitis, then, is that idiopathic morbid state whose phenomena 
are induced by the action of certain special agencies, such as heat, 
cold, poisons, and traumatism. The inflammatory process may in- 
volve the superficial or deep portion of the integument, or may 
extend to the subcutaneous tissues, or even deeper. The symptoms 
vary with the nature of the cause, the extent and degree of its influ- 
ence, and the circumstances attending its operation. Hyperemia 
usually precedes aud may be followed by a fluid or plastic exudate, 
by the production of one or more of the several recognized cutaneous 
lesions, by diphtheritic deposits upon the surface, or by gangrene. 
With these there may be general symptoms of mild or severe grade, 
due to the influence excited by the local process upon the general 
economy. 

[A.] Dermatitis Traumatica. 

External violence, various in character and severity, is capable of 
inducing dermatitis whose symptoms differ in degree, though their 
career is, in general, the same. In this list are included the inflam- 
mations produced by surgical interference with the continuity of the 
integument ; excoriations caused by scratching, by the friction of 
garments and other articles injuriously acting upon the skin ; by 
the various implements handled in the trades ; and by the bites and 
stings of beasts, insects, reptiles, and fishes, when the result is trau- 
matic and not toxic in character. These injuries may be in the form 
of contusion, blow, concussion, pressure, puncture, incision, or lacera- 
tion ; aud the consequences are declared in heat, swelling, redness, 
and pain ; and in itching, burning, stinging, or pricking sensations, 
with subsequent inflammatory symptoms varying in grade from mild 
and transitory hyperemia and exudation to severe grades of inflam- 
mation with consequent production of pus, granulation, and repair ; 
or gangrene, and separation of the slough ; or, finally, by repair 
without consequences. 

[B.] Dermatitis Venenata. 

Certain medicinal and other substances applied to the external 
surface of the skin are capable of exciting inflammation either by 
operating as caustic, irritant, toxic, or even traumatic agents. In 
this list are included most of the strong acids and alkalies ; croton 
oil ; cantharides ; mustard ; tartar emetic ; mezereou ; the compounds 
of mercury ; arnica ; turpentine ; ether ; chloroform ; the tarry com- 
pounds ; many of the dyes ; several members of the rhus family (the 
Rhus toxicodendron and Rhus venenata, poison ivy, poison oak) ; the 



186 DISEASES OF THE SKIN. 

nettle ; the smart-weed (Polygonum punetatum) ; cowhage (Mucuna 
pruriens) ; and glass in fine powder or delicate filaments, such as are 
thrust into the skin when handling certain articles of Venetian glass- 
ware. The list might be indefinitely extended, as there are few 
articles which are not capable of producing some irritation of the 
surface of the skin, if applied to it with sufficient vigor and for a 
certain period of time ; and in some it is difficult to decide whether 
the effect is more traumatic or toxic. An almost equally long list of 
substances of animal origin might be also named having poisonous 
effects upon the integument, such as decomposed or ammoniacal urine, 
feces, ichorous pus, pathologically altered secretions from the uterus, 
eye, ear, nose, etc. 

The symptoms of dermatitis venenata are substantially such as 
have been already described. Numerous types of cutaneous lesions, 
macules, pustules, papules, vesicles, bullae, wheals, scales, crusts, free 
serous aud purulent discharges, subcutaneous abscesses, and even gan- 
grene with sloughing, may result from the operation of such causes, 
the result being largely proportioned to the character of the agent 
producing the injury. 

A few of the more common sources of such accidents may be briefly 
considered. 

The use of soap for laundry, toilet, or other domestic purposes, 
containing an excess of alkali, or even minute particles of bone, is a 
frequent source of trouble, as are also several of the proprietary arti- 
cles sold in the shops for similar employment. In these instances, 
the erythema, vesiculation, infiltration, or other symptoms, will 
naturally be distinguished on the hands, or the hands and the face. 
Stockings and other undergarments dyed with aniline, picric acid, 
chromium, or arsenic, the leather lining of the inside of the hat or 
the cap, and the painted toys to which the lips of children are ap- 
plied, will beget mischief in the various regions of contact for each. 
Duhring reports cases where the dye-stuff in the lining of shoes 
penetrated the material of the stockings in women, and produced 
dermatitis of the feet or legs. 

The tincture of arnica, an article unfortunately much used as a 
domestic application for contused and incised wounds of a simple 
character, has produced very serious annoyance in some cases, two 
such having been recently presented at the author's clinic. 

The number of these accidents is annually increasing. Cartier 1 
reports excessive erysipelatous swelliug, a phlyctenular eruption, and 
submaxillary adenopathy resulting from the external use of arnica. 
Beauvais reported to the Paris Medical Society gangrenous results in 
one case. Buehner believes this poisonous action to be due to insects 
(particularly the atherix maculatus) found in the calyx of the arnica 
flower. 

Other native plants, a large number of which are enumerated in a 
valuable work by Dr. James C. White, 2 presented before the American 

1 Lyon Med.. April 13, 1884. 2 Dermatitis Venenata, Boston, 1887. 



DEKMATITIS. 187 

Derraatological Association in 1886, are similarly effective. Wesener 1 
reports that the Malacca bean tree (Auacardiuni Orientale) furnishes 
a caustic oil, called cardol, or cardoleum prurieus, which produces, 
after application to the skin, vesicles aud vesico-pustules which con- 
tain cardol and terminate by crusting. He reports a generalized 
eruption, beginning on the face, due to this cause. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive troubles. Among these may be named iodoform, which 
has produced erythema, vesicles, pustules, and wheals. 2 Carbolic 
acid and corrosive sublimate dressings have had similar effects. 
Many of the articles employed therapeutically by the dermatologist 
should be placed in the same category. Dr. N". E. Green, 3 of London, 
reports severe oedema of the skin followed by desquamation, resulting 
from the application to it of the ointment of ammoniated mercury in 
the strength of two drachms (8.) to the ounce (32.). 

Leszinsky reports a case of dermatitis following the use of a " triple 
extract of heliotrope " as a toilet preparation over the face. 

An exceedingly common source of such dermatitis is urine retained 
upon underclothing in adults. A persistent dermatitis of the scrotum, 
perineum, or inner faces of the thighs in either sex, always calls for 
a careful examination as to whether a few drops of urine are left in 
contact with such underclothing after each act of micturition. Fis- 
tula?, urinary incontinence, prostatic disease, u stammering of the 
bladder," imperfect finish of the coup de piston in men, especially 
after a gonorrhoea, and similar troubles, are all to be remembered. 

The eruption produced by the poison ivy and other varieties of 
rhus, is almost exclusively an American disease ; and from its fre- 
quency in this country has attracted a great deal of attention. A 
certain degree of susceptibility to the poisonous action of the plant is 
requisite for the production of its effects, as some individuals can 
handle the leaves of the plant with impunity, and others are said to 
be affected by its exhalations within a circle having a radius of several 
feet. It is, however, difficult to demonstrate the truth of the last 
statement, suspecting, as one may, that such instances are usually 
cases of contact with other than the suspected plant. The parts 
commonly affected are the hands and the regions to which the latter 
are carried, such as the face, genitals, arms, thighs, and neck. Bare- 
footed children suffer in the feet aud legs. Usually the symptoms 
are developed in the course of a few hours, and consist of erythematous 
patches, scanty or profuse vesiculation with abundant, serous weeping 
after rupture of the lesions, swelling, oedema, disfigurement, and 
intense burning and itching sensations. Serious effects are occasion- 
ally produced. The author has seen deeply attached scars result 
from subcutaneous abscesses of parts greatly swollen. Occasionally, 
in particularly sensitive skins, the eruption spreads from the surface 
affected by the poison, to that where presumably none has been 

1 Deutsche Arch. f. klin. Med., vol. xxxvi. p. 578. 

2 See paper of Dr. R. W. Taylor, read to the New York Academv of Medicine, 1887. 

3 Brit. Med. Journ., May 3, 1884. 



188 DISEASES OF THE SKIN. 

applied. It should be remembered, however, that articles of clothing 
may, for brief periods of time certainly, furnish sources of further 
trouble, being worn at the moment of contact with the plant, then 
laid aside, and, the occasion being forgotten, being subsequently 
employed. Thus a pair of undressed kid gloves after lying for two 
weeks untouched have sufficed to reawaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing of 
lacquered ware. This is manufactured from the rhus varnish. A 
few instances of such dermatitis have occurred in this country from 
handling the newly imported articles of this class. 

Careful observation of a typical case, soon after the onset of symp- 
toms, will disclose the exact surface of contact, each being delicately 
outlined by a reddened, tolerably well-defined line, within whose 
limitations will be seen a slightly tumefied, erythematous surface, at 
times displaying closely packed, pin-point sized papules, which may 
be embryonic vesicles, or may proceed to resolution without serous 
effusion. 

The diagnosis of the eruption will be aided by recalling the features 
described in a careful monograph on the subject by Dr. White, of 
Boston. 1 According to this author, the lateral surfaces of the digits 
first exhibit the symptoms of the eruption ; later, the dorsal sur- 
faces ; and latest, the thickened palms. The efflorescence also is 
more irregularly distributed, more uniformly vesicular, and the 
vesicles less transparent than in eczema. These lesions are, more- 
over, more vesicular, and less papular at the onset ; and, though 
suggesting papules by their situation in the palm, are in that situation 
readily made to exude serum by puncture with a needle. 

Internal medication is not required. The local treatment is that 
of acute eczema. The application of an alkali for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch) should evidently be considered solely 
with a view to prophylaxis, as it is difficult to understand how such 
neutralization can control the inflammatory process after its onset. 
The black wash, solution of sugar of lead, or oleated lime-water, 
should be employed at first, and be followed later by the dusting- 
powders. The late Prof. Babcock, of Chicago, a frequent sufferer 
from the disease during his extended botanical excursions, first taught 
the value of an ointment made by incorporating a decoction of the 
inner bark of the American spice-bush (Benzoin odoriferum) with 
cold cream. It certainly has afforded very prompt relief in the cases 
in which one is able to employ it, the difficulty lying in securing the 
bark of the shrub in its young and tender state. 

A long list of topical remedies have been vaunted as specific for the 
relief of this disorder, from the brine of a pork-barrel to a decoction 
of the leaves of the plant itself. As the eruption subsides with satis- 

1 New York: D. Appleton & Co., 1878, from the March number of the New York Medical 
Journal of the same year. 



DERMATITIS. 189 

factory results when protected and not irritated by the local treatment, 
it is not difficult to explain these facts. In this way corrosive subli- 
mate lotions ; the tincture of iron ; bromine, fifteen drops to the ounce 
(32.) of olive oil (Brown); dilute nitric acid ; hyposulphite of sodium ; 
bicarbonate of sodium ; saturated solutions of chlorate of potassium ; 
and grindelia robusta, a drachm (4.) of the fluid extract to eight 
ounces (250.) of water, have all been found useful. 

[C] Dermatitis Calorica. 

Under this title are included those affections of the skin induced 
by extremes of thermal variation. 

Unduly high temperatures produce in the skin some redness and a 
slight degree of swelling, the color not completely disappearing under 
pressure. If the exciting agent be withdrawn before further effects 
are induced, the color first deepens, then becomes paler, and in twenty- 
four hours the process is usually concluded with a very delicate and 
transitory resulting pigmentation. 

Rays of heat and heated objects at a temperature above 125° to 
175° F. produce immediately, or after a brief interval, first an 
erythema, which disappears when the source of heat is removed ; 
second, after more prolonged exposure, the symptoms of active in- 
flammation and exudation. Vesicles or bullae, isolated or confluent 
according to the severity of the cause, may rise from a reddened skin 
which is usually intensely painful. These lesions are persistent or 
transitory, and generally filled with a clear serum, which exudes and 
dries into crusts after rupture of the chamber in which it was im- 
prisoned. At other times the serous exudation is so great that the 
epidermis rises in broad plates, from beneath which the serum is 
exuded. This process may terminate by a free production of pus 
upon the surface and gradual resolution. Adenopathy is a frequent 
concomitant symptom. In such dermatitis of extensive areas of the 
skin, the intensity of the process may awaken a violent fever • or 
death may result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality ; or, as 
Kaposi describes it, dense, coriaceous, and as white as alabaster, upon 
which, nevertheless, some vesicles may appear, and by their presence 
suggest a false conclusion as to the vitality of the tissues upon which 
they rest. In from eight to ten days the eschar is removed by sup- 
purative processes, and the scene is closed by the usual phenomena of 
granulation and cicatrization. The characteristics of the scar thus 
produced are, its great irregularity, its tendency to stellate radiation, 
and the production of ridges, folds, pockets, and bridles. 

Burns involving one-third of the surface of the body are of grave 
portent, and those affecting one-half are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little complaint 
as to pain. The causes of death in these fatal cases are often obscure, 
as the post-mortem results are usually negative. Gastric and duodenal 



190 DISEASES OF THE SKIN. 

ulceration are, however, often recognized Overheating of the blood, 
heart-paralysis, oligo-cythaemia, and actual destruction of leucocytes 
have all been supposed to be effective. In cases where life is pro- 
longed to the third day, the complications of pyaemia, erysipelas, and 
tetanus may arise. Lastly, exhaustion following fever, suppuration, 
haemorrhage, and visceral affections may lead to fatal results. 

In the treatment of the simplest burns, rest, lotions of lead-water, 
and cool water with the application of compresses, are usually suffi- 
cient to secure relief; occasionally the dusting powders may be 
substituted advantageously for these. In the cases where the serum 
is invited rapidly to the surface, with the production of vesicles and 
bullae, the latter should be gently punctured to give relief to the 
tension by the evacuation of their contents, but the roof-wall should 
be preserved, as it may subsequently form an attachment to the ex- 
posed derma beneath. The indication then is to exclude the air as 
perfectly as possible and to prevent suppuration, indications admirably 
met by the application of carbolated oil and lime-water with the 
Lister diessing. Continuous immersion in water of the temperature 
most agreeable to the patient, as practised by Hebra in cases of severe 
and extensive burning, produces speedy and certain amelioration of 
the pain, and a favorable condition of the wounds, though it does 
not avert a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the sup- 
purative process in the skin is both active and extensive. Disin- 
fection with a five per cent, solution of carbolic acid, or a two per 
cent, resorcin solution, should be followed by the application of pro- 
tective silk wet with a five per cent, solution of the sodic biborate, or 
sodic bicarbonate, and the whole enveloped either in borax-lint, 
antiseptic (mercuric iodide) avooI, carbolized gauze, or salicylated 
cotton ; over all, the impermeable rubber tissue should be wrapped. 

Nitzsche l first disinfects the surface thoroughly with carbolic acid, 
having previously protected the blebs, after which it is covered with 
a thick varnish of linseed oil and litharge mixed by the aid of heat 
with five per cent, of salicylic acid. When this is dry, a second coat 
is applied, and the whole finally covered with a thick layer of wad- 
ding retained in place by an elastic bandage exercising moderate 
compression. Cicatrization progresses beneath the dressing without 
changing the latter. When suppuration does occur, the upper layer 
of the wadding is removed, and dried salicylic acid in powder is 
sprinkled over the surface, the waddiug being afterward reapplied. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

In Congelatio, or dermatitis from congelation, there are also, 
usually in the milder forms, circumscribed erythematous patches or 
plaques, generally recognized under the name of Pernio, or chilblain, 
seated upon the digits or, more rarely, upon the face, and occasioning 
a disagreeable sensation of heat, smarting, or itching, especially after 

i Deutsche med. Zeit., 1881. 



DERMATITIS. 191 

the chilled part has again been warmed. They are bluish or pur- 
plish-red in color, and often seated on a slightly cedematous integu- 
ment. They are often cool to the touch, when subjectively hot. 
Authors have claimed that anaemia is a chief predisposing cause of 
the complaint, but it frequently occurs in perfectly healthy young 
people. Sir Erasmus Wilson has intimated that some cases of so- 
called lupus erythematosus of the hands belong to this category. 

In the second grade of inflammatory reaction from the state of 
contracted bloodvessels and pallid integument produced immediately 
by the action of cold, bulla? and vesicles form, with, in severe cases, 
underlying ulcers. 

In the third grade gangrene may occur, with and without the 
formation of bullae. The frozen part may become insensible, white, 
and cold, without the circulation in it of blood- and lymph-currents. 
From this condition reaction occurs, with the formation of an eschar, 
differing in depth according to the severity of the exposure to cold. 
If, however, over and beyond the interference with the circulation, the 
tissue itself has been destroyed, when reaction occurs the part falls at 
once into gangrene ; or bullae form larger than those described above, 
filled with sanguinolent serum ; or the skin is smooth, marbled with 
bluish lines, whitish, cold, and insensitive. Mortification ensues, 
followed by the well-known phenomena of the " line of demarcation," 
and in favorable issues, suppurative separation of the dead part, 
granulation, repair, and cicatrization. As the injuries induced by 
congelation are more frequent upon the extremities, the bones largely 
participate in the losses of tissue, especially those of the digits. Sep- 
ticaemia and a fatal result may follow. 

Chilblains are treated internally by the ferruginous tonics, particu- 
larly the tincture of iron ; externally by stimulant applications, such 
as those containing iodine, camphor, carbolic acid, tincture of benzoin, 
and balsam of Peru. Kaposi recommends : 



&. Pulv. camphorse 


gr. x ; 


50 


Cretae prseparat. 


Ei ; 


30! 


01. lini 


f.?ij; 


60 


Balsam. Peruvian. 


nix*; 


l| 



M. 

Frictions, with or without medication, are generally useful. The parts 
are to be carefully protected from pressure and undue friction effects. 

Dilute nitric acid and peppermint water in equal proportions, 
painted over the part for three or four successive days, have been 
recommended by Lapatin for the treatment of frost-bitten fingers 
and toes. Hydrochloric and pyroligneous acids, lemon-juice, collo- 
dion, and acetate of lead, both in lotions and poultices, are also 
recommended. Meurisse advises in the management of both severe 
ambustio and congelatio, that goldbeater's skin be applied over any 
salves or lotions employed over the surface. 

In cases of severe congelation, the circulation is to be cautiously 
restored by friction in an apartment where the air is cool, in order to 
prevent too energetic reaction. Friction with snow is employed with 
safety in our own country and in the steppes of Russia, where these 



192 DISEASES OF THE SKIN. 

accidents are frequent and grave in consequences. Perseverance for 
hours in this course is often rewarded with success in apparently 
desperate cases. Antiseptic dressings are usually demanded when 
sloughing and ulceration ensue. 

[D.] Dermatitis Medicamentosa. 

The importance of recognizing the fact that a given eruption is 
produced by an ingested drug can scarcely be overestimated from 
the point of view of the diagnostician. The errors committed in this 
connection are so frequent and so annoying to the patient that it is 
necessary for the physician to inquire very carefully before treating 
any cutaneous disease, as to the medicaments previously swallowed 
by the patient ; and also to be prompt to connect any aggravation of 
a cutaneous disease with remedies ordered by himself for internal use. 
The following is but an imperfect list of the drugs whose internal 
administration may be followed by an exanthem — imperfect, because 
without question many have yet to be recognized as possessing such 
an action. As to the modus operandi of such medicinal agents, for 
the most part our knowledge on this subject is purely conjectural. 
Some, for example, the iodide of potassium, are eliminated in part by 
the glands of the skin, and presumably have thus a local effect upon 
such emunctories ; others, and in this class, the author believes, 
should be included quinia, induce an urticaria scarcely to be distin- 
guished from an urticaria ab ingertis. Some, possibly, operate in 
either or both ways at different times or in different individuals. 
The absurdity of supposing that any disease can be " driven out " by 
the ingestion of such drugs should be relegated to the specious ignor- 
ance which first framed such an hypothesis. 

Acids. — The acids capable of producing macules, papules, ery- 
thema, desquamation, etc., are carbolic, nitric, tannic, benzoic (and 
benzoate of sodium), and boric (and borate of sodium). 

Modadewkow reports a case in which the pleura was washed out 
with a five per cent, solution of boric acid, a part of which was not 
removed. There occurred as a result an erythematous rash over the 
face, trunk, and extremities. 

Aconite — This drug is said to be productive at certain times of 
marked diaphoresis with the occurrence of vesiculation and consider- 
able itching. The diaphoresis in an irritable skin may be responsible 
for the trouble. 

Antipykine and Other Remedies of its Class manufactured 
by the action of glacial acetic acid upon the petroleum products. — 
Ernst * has been followed by many observers in recording rashes re 
suiting from the administration of antipyrine. The symptoms are 
discrete and confluent patches of bright red, scarlatiniform, erythema- 

i Centralbl. f. klin. Med.. 1885. 



DERMATITIS. 193 

tous, and pruritic macules or papules. Veiel (Arch. f. Derm. u. 
Syph., 1891, Hft. 1) reports oedema with bullae upon the lips and 
toes, and over the palate, with urticarial lesions of palms and soles, 
after ingestion of antipyrine. 

Arsenic. — Erythematous, vesicular, papular, and much more 
rarely pustular, bullous, and ulcerative lesions, occur upon the face, 
back, and hands, after the ingestion of arsenic. The well-known 
effects of the administration of the drug in toxic doses, upon the 
mucous membranes of the eyes, nose, and mouth, need not be 
described in this connection ; nor yet the grave, gangrenous symp- 
toms, with osseous necrosis, which have been observed in the workers 
with the metal. 

The author has seen a bright red, scarlatiniform blush with few 
isolated vesicles cover both shoulders of a young woman with a del- 
icate skin after taking three medicinal doses of Fowler's solution, the 
eruption being present, but less distinct upon the face and hands. In 
two cases the rash in poly morphic type was limited to the hands alone. 

A number of young patients have been sent to the author's clinic 
from that for nervous diseases, w T ho, having taken arsenic in the 
largest medicinal doses for relief of chorea, presented as a result, a 
dark discoloration of the skin of the chest and neck chiefly, but also 
of other parts of the body. This was suggestive of the bronzing 
seen in Addison's disease. In some instances there had been no 
other cutaneous symptoms. Guaita and Liege have noted these phe- 
nomena, usually in the fifth month after ingestion of the drug. 

By far the largest number of such rashes are, however, produced 
in those previously suffering from cutaneous disease, for whose relief 
the drug is administered. Here the toxic effect is declared either by 
— first, increased hyperemia of the skin visible in an erythematous 
patch, or beneath the scales of a squamous patch ; or, as an areola 
of bright red hue about any aggregations of lesions ; second, by 
simple aggravation of the type of a disease already in existence 
(recurrence of acuity in a subacute eczema); third, by rapid peripheral 
extension of a disease which had previously been well limited in 
contour ; fourth, by converting a disease exhibiting uniformity of 
lesions into one characterized by multiformity. Each of these results 
might be illustrated by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper hangings, and reported by Dr. F. H. Brown, 1 there were, 
curiously, no cutaneous symptoms. 

Belladonna, Atropia. — The well-known erythematous, scarla- 
tiniform, or reddish efflorescence produced by belladonna and its 
alkaloids, is usually limited to the upper segment of the body, but 
may become generalized. It is said to occur more frequently in 
children, probably because it has been administered largely to indi- 

1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 

13 



194 DISEASES OF THE SKIN. 

viduals of that age under the superstition that it is useful as a 
prophylactic in scarlatina. Very disagreeable and even dangerous 
results have followed the instillation into the eye of atropia as a 
mydriatic, the rash being accompanied by constitutional symptoms. 

Bromine and its Compounds. — A full and valuable account of 
the cutaneous effects of this drug and its compounds, when adminis- 
tered internally, is contained in a paper on medicinal eruptions, read 
by Dr. Arthur Van Harlingen, of Philadelphia, before the American 
Dermatological Association in 1880. Acneiform lesions, pustules, 
macules, maculo-papules, papules, eczema-form moist patches, fur- 
uncles, urticarial wheals, scales, and ulcers have been induced by 
swallowing the bromides of potassium, sodium, ammonium, and 
lithium. By far the most common are the acneiform and pustular 
lesions, occasionally accompanied by pruritus, which appear upon the 
face and upper portion of the trunk, though the author has seen the 
rash very distinct upon the genital region. Duhring reports an 
interesting observation of a case in which the eruption simulated very 
closely the maculo-papular syphiloderm, the patient having taken 
the remedy for three years. The eruption first appeared within five 
or six days after decreasing the dose. Kaposi has observed a case in 
a nine-months-old suckling, the mother having taken one hundred 
and twenty grammes of the bromide of potassium in two months, 
herself not exhibiting traces of eruption. In one patient treated by 
myself the eruption was generalized, but in no part exaggerated. It 
occurred in an adult male after three months' contiuual employment 
of large doses of the same salt. 

Mr. Browse, of Cambridge, England, recommends for relief of 
these symptoms the application of a solution of salicylic acid, one 
grain to the ouuce (0.066-32.) of water, frequently applied on lint, 
having successfully treated in this way sores as large as the palm of 
the hand. 

T. C. Fox and Gibbes report condyloma-form lesions in the case 
of an infant where the histology of the lesions was carefully studied ; 
aud Fay, in a child eleven months old, also recognized lesions which 
had been mistaken for molluscum epitheliale. These were undoubt- 
edly similar to the condyloma-form rash seen in children after the 
administration of the iodide of potassium. 

Cannabis Indica. — The only instance thus far reported of an 
eruption produced by the ingestion of this drug was observed by 
myself in the case of an adult male, who was extensively covered 
with papulo-vesicular lesions after swallowing a grain (0.066) of the 
extract. 1 

Chloral. — An erythematous rash is the most common of the 
eruptions produced by chloral, though wheals, red and yellowish 
papules, vesicles, pustules, and petechial blotches have been observed. 
It occurs upon the face, neck, trunk, and limbs, of the latter, especially 

i N. Y. Med. Record, May 11, 1878. 



DERMATITIS. 195 

on the extensor surfaces. In a man of advanced years, totally deaf, 
who had slept only under the influence of chloral for four years, the 
author observed discrete scaly patches as large as saucers over the 
lower extremities, hands, and feet. 

Martinet 1 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face, neck, front of the chest, the extensor surfaces of the 
larger joints, and the dorsum of the hands and feet. There was no 
pyrexia nor indisposition, but in cases dyspnoea and cardiac palpitation. 

Cod-liver Oil. — According to Farquharson, 2 cod-liver oil after 
being swallowed is capable of producing an acne. This can be true 
only of very inferior specimens, such as are not rarely found in the 
English market. 

Copaiba axd Cubebs. — The ingestion of copaiba is occasionally 
followed by a vividly red rash, in the form of discrete macules, more 
rarely maculo- papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering 
the surface. The author has seen the rash occur in dark mulberry- 
red petechia? ; and always in his experience accompanied by pruritus. 
Inasmuch as the drug: is often administered for the relief of a venereal 
disorder not syphilitic, care should always be taken not to confound 
the eruption it may excite with the early macular syphiloderm. 
Cubebs is much more rarely followed by a similar result. 

Cundurango. — Guntz 3 reports the occurrence of furuncular and 
acneiform lesions in twenty patients out of one thousand who were 
taking cundurango for the relief of syphilis. 

Digitalis. — In Behrend's treatise on diseases of the skin 4 refer- 
ence is made to cases where macular and maculo-papular rashes suc- 
ceeded the ingestion of digitalis. 

Iodine and its Compounds. — The iodide of potassium is respon- 
sible for the larger number of all eruptions in this category. The 
frequent employment of this drug and the very marked influence 
which it possesses over the skin, render the study of these morbid 
results important. 

Unlike many of the other substances in the list, the iodine com- 
pounds are followed by some species of rash in probably the larger 
number of all persons who swallow them. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or in the form of circumscribed, sub- 
cutaneous abscesses. 

The macular rash is best seen fully developed over the upper 
extremities, in discrete erythematous patches or in a diffuse blush. 
The cases in which the author has studied it, all displayed symmetry. 

1 These de Paris, 1879. °- Brit. Med. Journ , Feb. 22, 1879. 

3 Vierteljahrschft. f. Derm. u. Syph.,1882. * Braunschweig, 1879. 



196 DISEASES OF THE SKIN. 

The hands were chiefly affected, and suggested in appearance the dyed 
hands of the aniline worker. It is said to assume at times the papu- 
lar type, a transformation the author has not noticed, though he has 
seen coexistence of papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence 
upon the surface of which were numerous minute discrete vesicles. 
Eczema-form eruptions with abundant serous exudations are also 
reported. 

A number of interesting cases are on record where the adminis- 
tration of the drug was followed by the production of bullae. Bum- 
stead, Taylor, Duhring, Tilbury Fox, and Finny, have described 
such in adults, and the author has seen several cases in children. 1 
Hallopeau 2 also reports a case in which a bullous eruption followed 
the ingestion of the iodide of potassium. The patient died, and the 
post-mortem appearances are reported in full. The eruption occurred 
chiefly about the head, neck, and the upper extremities. The author 
has called attention to the significant rarity of vesicular and bullous 
lesions in acquired syphilis, and suggested that at least some of the 
cases on record were those of rashes induced by the remedy given for 
relief of the disease. 

A careful analysis of these bullous rashes leads to their division 
into three categories : first, those occurring often with fatal results in 
cachectic adult patients ; second, those occurring as part of the erup- 
tive lesions in a polymorphic group ; third, those occurring in well 
nourished children, taking on the appearance of molluscum epitheliale 
and condyloma lesions, usually compounded of papulo-vesicles and 
pustules. Erythanthemata of a similar type have been also recognized 
in infants after the ingestion of bromide of potassium. 

The pustules induced by the administration of iodine compounds 
are seen chiefly upon the face, neck, trunk, and arms. They are 
usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular 
violaceous mass, nearly two inches in diameter. On several occasions 
the author has observed large cherry-sized, tubercular elevations 
abruptly rising from the surface of the integument, and presenting 
a cribriform appearance, which showed the open ducts of several sup- 
purating follicles (chin, cheek, nose). 

The purpuric rash occurs in petechial macules, discrete and miliary, 
situated chiefly on the lower extremities. In a case reported by Dr. 
Mackenzie (quoted by Van Harlingen) a single dose of two and a 
half grains (0.166) in an infant, was followed by a fatal result after 
the petechias appeared. 

Jaborandi and Pilocarpine are capable, when ingested, of 
inducing free diaphoresis ; and erythematous macules, wheals, and pin- 
head sized papules have been seen upon the surface as a result. 

i Arch, of Derm., Oct., 1870. Journ. of Cutan. and Ven. Dis., 1886, p. 383. 
2 Union Med., March 25, 1882. 



DERMATITIS. 197 

Mercury. — The statement that mercury when ingested is capable 
of producing an erythematous rash upon the surface of the skin is 
made by several authors of reputation. In view of the fact that the 
metal has been, in its various compounds, administered for so long a 
period of time, and for so many various diseases without the produc- 
tion of cutaneous symptoms, it is a fair hypothesis that the few 
reported cases are those in which there was coincidence rather than 
causation. The author has had the opportunity of observing a large 
number of individuals in whom the drug had been both properly and 
very injudiciously employed for long periods of time, and has not 
been able in a single instance to discover any evidences upon which to 
base a belief in its power to produce a cutaneous exanthem. A 
similar statement was made by Dr. White, of Boston, when this 
subject was under discussion in the American Dermatological Associa- 
tion. Mercurials, when applied to the external surface of the body 
are, as is well known, capable of exciting, in various degrees, cuta- 
neous irritation and inflammation. 

Opium axd its Alkaloids. — Erythema, wheals, and occasion- 
ally intense pruritus, with oedema, and subsequent desquamation, 
have followed the ingestion of opium and several of its alkaloids, 
notably morphia. In its mildest expression this cutaneous effect is 
limited to a characteristic itching about the nostrils, which can be 
perceived in a large proportion of all patients as soon as the general 
effect of the opiate becomes apparent. In several cases the author has 
observed an intense and distressing general pruritus without efflor- 
escence ; and in some instances has been certain that the subsequent 
urticarial efflorescence was induced by the free diaphoresis which the 
medicament induced. This is a matter of some practical moment, 
as the use of an anodyne for the purpose of procuring sleep for a 
patient tormented with a nocturnal pruritus would seem to be 
occasionally indicated. Inasmuch as chloral, the bromide of potas- 
sium, and the opiates are all capable of aggravating such distress, 
great caution is in such emergencies needful. In general, it may 
be said that the employment of these and similar remedies for such 
a purpose should be interpreted as a confession of weakness on the 
part of the physician, who ought to be able to alleviate the distress 
of his patient by a judicious employment of topical remedies. 

Petroleum and its products are responsible for a large list of 
medicamentous rashes. 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case 
of a young girl who exhibited a pemphigoid rash after the ingestion 
of phosphoric acid ; and, according to Farquharson, 1 phosphorus 
itself is occasionally responsible for purpura with gastro-intestinal 
derangement and jaundice preceding a fatal issue. 

1 Loc. cit. 



198 DISEASES OF THE SKIN. 

Podophyllin. — Winterburn 1 reports that those who work in 
resinoid podophyllin are liable to suffer, as a consequence of this 
exposure, from a cutaneous disease of the scrotum. 

Potassium Chlorate. — Stellwagon and others report that 
papules and macules have followed the use of this remedy, adminis- 
tered in the form of tablets. 

Quinine, Cinchona, and its Alkaloids. — Morrow 2 has col- 
lected in an interesting paper, the record of over sixty cases of 
quinine exanthem, and shows that its prevailing type is exanthe- 
matous, the rash being of a bright vivid hue, disappearing on 
pressure, aud resembling scarlatina. Other lesions produced are 
wheals, papules, vesicles, petechia?, hsemorrhagic purpura, bulla?, and, 
in one instance, an intense localized dermatitis with commencing 
gangrene of the scrotum. In some cases the rash reappeared on 
repetition of the dose, and even after recourse to the other alkaloids. 
The subjects were mostly women. As with most of the other exan- 
them-producing drugs, small doses, where the idiosyncrasy existed, 
sufficed for the effect. The author has seen the rash in an adult male, 
who, after taking two grains (0.133) of the sulphate of quinia 
for the first time in six years, exhibited an efflorescence over the 
entire surface of the body, of discrete, finger-nail sized, salmon- and 
pinkish-tinted, scarcely elevated patches, accompanied by a moderate 
pruritus. A repetition of the dose was followed by a recurrence of 
the exanthem. 

In several cases desquamation is reported as resulting from the 
rash. As to the occurrence of the general symptoms recognized 
under the title of cinchonism (tinnitus aurium, etc.), these may and 
may not accompany the lesions. Morrow makes the pertinent sug- 
gestion, in view of the frequent similarity of the rash to that exhib- 
ited in scarlatina, that many cases hitherto recorded as recurrent 
attacks of that disease and measles, with other anomalous cutaneous 
eruptions, may have been instances of the quinine exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases 
where these substances after ingestion have produced cutaneous 
symptoms have been made by Heinlein, Wheeler, and Freudenberg, 
all cited by Van Harlingen. The symptoms were diffused redness, 
urticarial lesions, vesicles, pustules, petechia?, and vibices, accom- 
panied by intense pruritus, and followed by desquamation. 

Santonine. — A generalized eruption of urticarial lesions seated 
upon a reddened surface, and accompanied by oedema, is reported 
by Sieveking as occurring in a child to whom santonine had been 
administered as a vermifuge. 3 

i Louisville Med. News. April 21. 1882. 2 n. y. Med. Journ., March, 1880, p. 244. 

3 British Medical Journal, February 18, 1871. 




DERMATITIS. 199 

Sodium Benzoate. — Rohe 1 reports two cases in which an ery- 
thematous rash, with well-defined border, accompanied by itching and 
slight desquamation, occurred during the use of the benzoate of 
sodium. The patients were a woman, aged thirty-five, and a boy 
with diphtheria. The eruption disappeared on the discontinuance of 
the remedy, and was made successively to appear and disappear by 
its alternate use and disuse. 

Sodium Biborate. — Gowers 2 reports the occurrence, especially on 
the arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of the biborate of sodium. Some of the 
resulting patches were one inch and a half in diameter. Three cases 
in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. — Deschamps (cited by Duhring) reports au erythem- 
atous rash after the administration of the thorn-apple. 

Strychnia. — Skinner (cited by Van Harlingen) reports a case 
where an eruption of six weeks' duration ensued upon the adminis- 
tration of quinine and strychnia together ; the former in the dose of 
one and a half grains (0. 10), the latter in the dose of one-twenty- 
fourth of a grain (0.0025). 

Tanacetum. — A varioliform eruption produced by the ingestion 
of a drachm and a half (6.) of the oil of tansy, administered for 
abortifacient purposes, is reported by Potter. 3 There were antecedent 
clonic convulsions. The result was not fatal. 

Tar and Turpentine. — Erythematous, vesicular, and papular 
rashes are reported as resulting from the ingestion of these substances. 

The following named medicaments have been recently added to the 
list of drugs capable, when administered by the mouth, of producing 
rashes. Many of these drugs have been effective in but few instances. 
There is no reason why the list should not be in the future greatly 
enlarged, as it is probable that every medicament is capable of pro- 
ducing a temporary effloresence when the system is suffering from a 
special sensitiveness to its action : 

Anacardium, bitter almonds, antimony, bittersweet, capsicum, 
cantharides, chloroform (after administration for anaesthetic pur- 
poses), duboisia, creasote, resin, castor-oil, ipecacuanha, hyoscyamus, 
matico, lead and its compounds, sulphur and the calcium sulphide, 
veratrum viride, cocaine, and conium. 

The diagnosis of the various medicinal rashes described above does 
not, fortunately, demand a recognition of the essential peculiarities 

1 Maryland Medical Journal June 15, 1881, p. 91. 2 Lancet, September 24, 1881. 

3 New England Medical Journal, October 15, 1881. 



200 DISEASES OF THE SKIN. 

impressed upon each by the exciting cause, since in many cases such 
peculiarities do not exist. The urticarial resulting from the ingestion 
of "head-cheese," quinine, and chloral may be absolutely indistin- 
guishable. But to establish the fact that a medicamentous eruption 
is present in any given case is a long step in the direction of reaching 
the precise cause that has been in that case effective. This fact 
must often be obtained from the lips of the patient. The medicinal 
rashes are in general remarkable for their sudden appearance, their 
symmetry, their diffusion over large areas of the integument, the 
presence of pruritus, the absence of fever, and their existence alike 
upon exposed and protected surfaces of the skin, hinting thus at the 
action of some cause not operating externally. Excluding syphilis 
and the exanthematous fevers, a generalized rash of suddeu occurrence 
should always raise the suspicion of a dermatitis medicamentosa. 
Similarly in cases of pre-existing cutaneous disease, syphilis, eczema, 
or psoriasis, the sudden occurrence of lesions of a new type widely 
diffused, or of rapid aggravation in situ, or of speedy extension as to 
area of those already in existence, should awaken the suspicion, if 
there be fever, of the exanthemata ; and, without a febrile process, of 
the medicinal rashes. Thus the author has seen two patieuts with 
eczema exhibit rapid rise in temperature, and subsequently develop a 
generalized variolous rash j and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or even long 
past the eruptive stage of that disease, showing their faces, necks, and 
shoulders covered with an acueiform rash produced by the potassium 
iodide. The practitioner cannot be too strongly urged to view with 
exceeding watchfulness the skin of any patient affected with either of 
the common disorders, eczema, acne, and psoriasis, when the eruption 
in any instance becomes anomalous as to type, distribution, or symp- 
toms. An illustrative example has come under my observation since 
the first paragraph of this chapter was written. A physician, on a trip 
from Colorado to Chicago, with a long-standing eczema of the scrotum 
and thigh, suddenly exhibited tumefaction of both hands with small 
egg-sized, discrete, dull-red plaques over the palms and dorsa; and in 
the centre of nearly all such lesions a firm, whitish, elevated wheal, 
accompanied by severe burning, tingling, and pricking sensations. 
He had been swallowing " bromidia," a proprietary preparation con- 
taining the bromide of potassium, the hydrate of chloral, and cannabis 
indica, each single drug being capable of inducing an exanthem, and 
yet he had not the slightest suspicion of the real nature of his symp- 
toms, having been questioned by a brother physician, to whom he 
exhibited his hands, as to the possibility of syphilis. 

The medicamentous rashes, as a rule, disappear rapidly after the 
withdrawal of the exciting cause, and require no further manage- 
ment. In some cases the soothiug lotions, baths, and dusting powders 
employed in the treatment of acute eczema may be required. 

It should not be forgotten that the patient who exhibits these 
lesions is usually one who has been suffering from the real or fancied 



DERMATITIS. 



201 



disease for relief of which the drug was taken, and that condition 
may require recognition and management. 

In Morrow's contribution to this subject, it is clearly shown that 
the same drug may produce a variety of eruptive phenomena, and 
that the same eruptive features may result from the ingestion of 
different drugs. He points to what he concludes to be the neurotic 
origin of many of these rashes, and believes that the proof is incon- 
clusive that these are, to any considerable degree, brought about by 
elimination, through the cutaneous glands, of the noxious element 
introduced with the drug. Tilden, however, calls attention to the 
fact that many of these eruptive phenomena are of the nature of 
angioneuroses, similar to Trousseau's " tache cerebrate ," requiring 
often increase in the irritability of the cutaneous vessels, with exuda- 
tion of serum, outwandering of cells, and, in case of hemorrhagic 
lesions, some change in the vascular walls themselves. 



Fig. 41. 



Feigned Eruptions are usually varieties of dermatitis (erythem- 
atous, bullous, traumatic), discolorations, or ulcers produced by acids, 
caustics, other chemical agents, or friction for the purpose of exciting 
sympathy, extorting charity, securing hospital comforts, transporta- 
tion to city life, etc. The persons 
employing these devices are, as a 
rule, criminals, hysterical young 
women, mendicants, soldiers, 
sailors, or servants seeking release 
from service. The peculiarities 
of these artificial eruptions are 
briefly : their odd appearance, 
not resembling the well-known 
types of ordinary disease ; their 
sharp definition, due to the limi- 
tation of the disease to the area of 
contact of the article employed in 
its production ; and their appear- 
ance on the parts most accessible 
to the hands and eyes of the sup- 
posed victim of the disease, being 
in right-handed persons most 
perceptible on the anterior por- 
tions of the body, particularly 
over the face of the right thigh 
or leg, and over the left arm or 
shoulder. Evidences of drops 
where a caustic liquid has been 
spilled over the surface ; of angu- 
larity in outline, due, as a rule, to 
downward flow of a fluid from above ; and of staining of fingers, or 
nails, or tissue beneath the latter by the operator, are all significant. 




Feigned eruption. 

[From a photograph of one of the author's 

patients.] 



202 DISEASES OF THE SKIN. 

A " Chronic Pustular Dermatitis with Extension in 
Peripheral Patches," has been described and figured by Hallo- 
peau {Int. Journ. of Rare Skin Diseases, iii., 1890, 1). The trunk 
and thighs were extensively covered with large deep brown plaques, 
having defined borders, and exhibiting indurated projections of the 
size of a small coin here and there over the indurated integument. 
The elementary lesion was a vesico-pustule with a red areola, which 
spread centrifugally by multiplication and which eventually became 
covered with a crust. 

[E.] Dermatitis Gangrenosa. 

Gangrene of the skin may result from dermatitis originally due to 
the action of excessive cold or heat ; to the action of externally ap- 
plied chemical agents (caustics, strong acids, alkalies, etc.) ; to shock ; 
to ergot and other substances ingested ; to infectious diseases (lepra, 
tuberculosis, syphilis, erysipelas) ; to central nervous disease (decubi- 
tus, Raynaud's disease) ; to disorder of the vessels (embolism, throm- 
bosis, acute and chronic endarteritis obliterans, calcareous changes in 
the arterial vascular tunics) ; or to compression by ligature, or 
tumors. 

Spontaneous Gangrene of the Skin occurs chiefly in hys- 
terical female subjects, the affected plaques being irregular in outline, 
superficial or deep, which after the slough has been separated usually 
cicatrize without serious mischief resulting. Occasionally they 
spread in serpiginous directions over the surface. Though doubt 
has been cast ou these cases, in consequence of the discovery among 
them of feigned diseases, it is certain that the malady occurs as de- 
scribed without the operation of external agencies. These cases are 
included in those described elsewhere as erythema gangrsenosum. 

Dermatitis Gangrenosa Infantum. (Multiple Disseminated 
Gangrene of the Skin in Infants ; Varicella Gangrsenosa ; Pemphigus 
Gangrsenosus ; liupia Escharotica ; Gangrenous Infantile Ecthyma). 
— As a consequence of the exanthemata (variola, varicella, rubeola, 
purpura, erythema nodosum), the head, shoulders, and trunk of some 
children exhibit crust-covered lesions which ulcerate and finally 
throw off a gangrenous slough, split-pea to small coin-sized, deep 
or shallow, after which repair commonly sets in. Severe losses are 
produced by a species of coalescence of smaller ulcers. 

These gangrenous points may occur beneath some previously exist- 
ing lesion or crust ; or may be at the outset spontaneous. In the 
most of cases a vesicular lesion forms with rosy areola which 
speedily bursts, leaving a blackish slough about which a circle of 
eliminating inflammation spreads. Thromboses result in the blood- 
vessels of the neighboring parts ; oedema becomes apparent ; and 
there is excited a train of reactive symptoms, fever, vomiting, diar- 
rhoea, albuminuria, cardiac or pulmonary troubles. The patient 



DERMATITIS. 203 

becomes greatly reduced. Crocker reports hemorrhagic vesicles and 
bullae in grave cases. 

Brocq is careful to distinguish between these grave forms of dis- 
ease aud those to which should be denied the appellation dermatitis 
gangrenosa. In these milder forms the vesicular lesions of varicella, 
accompanied by a mild fever, and occurring perhaps in crops, develop 
in course ; while some among them are covered with a blackish crust, 
indurate at the base, surround themselves w T ith an angry zone of 
inflammation, and, especially about the trunk, thighs, and ano-genital 
region, ulcerate beneath the crust. Even though these ulcers coalesce 
and acquire a grave aspect, the result as a rule is not unfavorable. 

Etiology and Pathology. — The subjects of this affection are infants 
and young children, from three months to several years of age. 
Besides the exanthemata which may precede, cases are on record fol- 
lowing tuberculosis, rickets, and syphilis. The process is one 
which, originally dependent upon the toxic effects of specific cocci, 
evidently requires a certain soil for its effective operation. 

The treatment should be supporting for the general system, and 
local antisepsis by the aid of boric acid solutions, aristol, iodol, and 
the dressing of the parts which slough by the usual deodorizing 
agents. The prognosis is at times grave. 

Multiple Gangrene in Adults. — Under this title, Crocker 
describes two cases, one in a male, a second in a female patient, 
where as a consequence of scarlatina or some poorly defined antece- 
dent disorder, crops of pustules followed by gangrenous sloughing 
occurred in almost all parts of the body, one attack rapidly following 
another w 7 ith rise of temperature. 

Spontaneous Gangrene of the Eyelids. — (Hilbert). A 
pustulo-crustaceous lesion of the upper lids with gangrene resulting 
in a small circular ulcer, is reported as of occurrence in two healthy 
children. 

Symmetrical Gangrene of the Extremities. — {Local As- 
phyxia, Raynaud's Disease.) 

This affection is usually first announced by the common signs of 
arrest of circulation in the capillaries, numbness, loss of sensibility, 
and color of passive congestion (local asphyxia, digiti mortui), in 
fingers and toes exposed to extremes of cold or heat. The face, 
nose, ears, brows, and other regions and organs may also be involved. 
Eventually subjective sensations are awakened, stinging and lancinat- 
ing pains, pricking and crawling sensations. The parts involved, 
often the second and third phalanges of the digits, become first livid, 
then cold, firm, and black, and the epidermis over them rises in 
bullous efflorescences, which speedily become ulcerative lesions, 
sphacelation ensuing in the course of a few hours or days. Varia- 
tions occur in a singular thinning of the digits, which may become 
indurated and slender ; or be covered with small whitish cicatrices 
where a superficial slough has been separated ; or the parts become 



204 DISEASES OF THE SKIN. 

cool, white, like alabaster, and recover their tone without loss of 
tissue ; the nails alone may fall ; or indeed the entire process may 
meet with arrest in the early stage of blueness and asphyxiation of 
the extremities. 

Etiology and Pathology. — The disease occurs equally in the two 
sexes and at all ages ; often in the cold weather of the winter season. 
There is a growing suspicion that many cases are of syphilitic origin, 
as these have followed infection. It has also succeeded tuberculosis, 
diphtheria, the exanthemata, diabetes, and hemoglobinuria. It is 
without question due to either centric or peripheral nerve excitation ; 
and immediately produced by venous stasis. 

Treatment is by employment of the galvanic current, stimulation 
(as in dermatitis with congelation) ; and friction with stimulating 
lotions, alcoholic, camphorated, oleaginous. It is desirable to apply 
both electricity and (in some cases) dry cupping over the spinal 
region. 

The Prognosis is in some cases grave ; when the morbid condition 
is limited to a small part of the body, recovery is often satisfactory. 



Erysipelas, 

Gr. epvdpdg, red ; ireXka y the skin. 

Erysipelas is an acute and specific inflammation of the skin and subcutaneous 
tissue, characterized by diffuse, shining redness, pain, swelling, and elevated 
temperature of the affected part, terminating in desquamation, and usually 
accompanied by fever, due to the presence of the streptococcus erysipelatis. 

Symptoms. — The disease is usually preceded by a prodromic period 
of malaise, lasting for tweuty-four hours or less, which may be 
ushered in by one or several chills followed by febrile symptoms. 
The latter are accompanied by anorexia and often by vomiting, with 
general depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first 
noticed in a nut- or egg-sized patch, the integument of which is 
tumid, slightly elevated, irregular in contour, distinctly circum- 
scribed, and presents a rosy or crimson-reddish color with a pecu- 
liarly smooth and characteristic shining or glazed appearance. The 
sensations awakened may be those of moderate pruritus, pain, heat, or 
burning. To the touch, the affected part is tender, moderately firm, 
and perceptibly hotter than normal. The color fades under pres- 
sure to a yellowish-white. 

In typical cases, the erysipelatous blush and swelling spread over 
an area which may be of the size of the palm, or may even cover 
the surface of an entire limb or region of the body. In cases of 
moderate grade, the inflammation attains a maximum of extent and 
severity within a week, remains apparently unaltered for a day or 



ERYSIPELAS. 205 

more, and then begins to abate, with amelioration of all the concom- 
itant symptoms. The fever which often precedes the eruption, con- 
tinues unabated during its progress, the temperature rising to 105° 
or 106° F., with nocturnal exacerbation, cephalic and lumbar pain, 
dryness of the tongue, gastric distress, and occasional delirium. As 
involution of the disorder is accomplished, the redness is replaced 
by the brownish, bluish-red, and dirty-white shades often seen after 
the disappearance of erythema multiforme, the epidermis finally 
desquamating in various degrees according to the extent of the pre- 
ceding inflammation. 

In other cases, where the exudation of serum beneath the epidermis 
has been rapid, the latter is raised in the form of vesicles, pustules, 
or bullae, more often the latter ; and, precisely as in the severe forms 
of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. This 
is particularly apt to follow the disorder when it attacks the seat of 
surgical wounds and injuries. 

Erysipelas Ambulans is a term used to describe that form of 
the affection in which the erysipelatous blush, after involving a 
given area, spreads with greater or less rapidity to the parts in the 
vicinage, either by direct extension and uniform advancement in one 
direction, of the tumid and distinctly circumscribed border; or by 
linear, digital, or irregular prolongations radiating from the inflam- 
matory focus. As the blush and swelling advance in one direction, 
there is usually correspondingly rapid disappearance on the other. 
At other times, the disease, while extending to a new area and 
abandoning the old, is relighted in the latter, and thus an irregu- 
larly involved and irregularly extending erysipelatous surface pre- 
sents for weeks the varying phenomena of the disease. In yet other 
cases again, chiefly those in which there has been a history of trau- 
matism, a long erysipelatous linear streak or band may spread from 
the site of the traumatism in one direction or another, suggesting 
the indurated lines observed in lymphangitis. In severe cases, the 
febrile, nervous, and other symptoms are grave, including coma, 
delirium, meningitis, and the signs of serious involvement of the 
lungs, pericardium, pleura, and bowels. Metastatic abscesses may 
also occur in the cutaneous and subcutaneous tissues, the joints, peri- 
toneal cavity, and even in the viscera. Death may result from these 
complications, or from shock, exhaustion, or pyaemia. 

Surgical accidents aside, the face is the most common seat of the 
disease, where it may be first seen upon one side of the nose, one 
cheek, the lips, or the eyelid. It often attacks the lobe of the ear 
after the operation of piercing the lobule for the insertion of ear- 
rings in women. Thence it may extend over the whole face, inclu- 
sive of the mucous linings of the mouth and nose, which present a 
dry, tumid, and glazed appearance, suggestive of the symptoms dis- 
played upon the skin. 



206 DISEASES OF THE SKIN. 

The inflammation may extend to the hairy parts, but in many 
cases it exhibits a species of reluctance to transgress the limits there 
presented. It may be noticed in cases of mild grade where no appli- 
cations have been made to arrest a local progress, that the elevated 
border spreads symmetrically to within a few lines of the male 
beard or the hairs at the edge of the forehead, and there spontane- 
ously rests. In severer grades these limits are readily surpassed ; 
and then, as a rule, the extension is rapid and formidable. In this 
way the entire head may become enormously swollen, suggesting to 
a casual observer that it is fully twice its normal size. The patient 
may then be greatly disfigured; his scarlet lips, swollen, parted, and 
permitting the escape of saliva; the ears, as usual when greatly en- 
larged, projecting in a marked degree from the side of the head ; the 
lids cedematous and incapable of separation ; the face, disfigured by 
bullae or crusts ; and the mind disordered by violence of the fever 
or the accesses of delirium. When recovery ensues, the hairs are 
apt to fall. 

All other regions of the body may be invaded, as the vaccinated 
arm, the leg w T hose skin is involved in venous varicosities, the 
scrotum or umbilicus of the infant, the genitalia of the newly deliv- 
ered woman, the breast of the nursing mother, and every surface 
which has been the seat of punctured, incised, contused, or poisoned 
wounds, or other accidents of the integument, where the germs of 
the disease may have access to the economy. 

Several authors describe habitually recurrent and Chronic forms 
of Erysipelas, whose identity with the disease here described it is 
difficult to establish. The diagnostician is sufficiently often con- 
sulted in cases where an erythematous eczema of the face, an acne 
rosacea, or a symptomatic erythema, is described by a patient as 
chronic or recurrent " erysipelas." The lesions to which such terms, 
however, are restricted by careful writers, are often forms of chronic 
dermatitis, such, for example, as occasionally follow dermatitis 
calorica. Instances occur in which the face, or parts of it, are the 
seat of a low grade of inflammation with local heat, swelling, red- 
ness, considerable infiltration, and some tenderness, the part being 
irritable and worse after exposure to a high wind or after excesses 
at the table. But the most of such cases fail to exhibit the distinct 
imprint of erysipelas ; they are not only chronic in course, but ex- 
ceedingly indolent, lasting for years ; they are unaccompanied by 
fever ; they are distinctly limited in all accesses of aggravation to 
the same part of the face ; they are never characterized by a bullous 
efflorescence; they never completely disappear; many occur in the 
subjects of chronic alcoholism, and the specific germs of erysipelas 
are not present. 

The febrile symptoms are, throughout, persistent and character- 
istic of a specific toxaemia. The temperature, as has been seen, may 
reach 105°-107°F., with vespertine exacerbations and remissions; 



ERYSIPELAS. 207 

it may also become subnormal. If not relieved in the course of seven 
or eight days, complications may be expected. These are oedema, 
abscess, phlegmonous inflammation, gangrene, and inflammatory 
accidents involving the membranes of the brain, lungs, heart, bowels, 
kidneys, peritoneum, and joints. 

Etiology. — The modern view of the invariable origin of erysipelas 
from some point, however insignificant as to size, where a morbid 
germ has secured access to the economy, is generally accepted and 
adds interest to the study of the local manifestations of the disease. 
Whether it be the slightest or severest traumatism, an erosion, a torn 
pustule, or a puncture by a pin, such lesions are now interrogated 
whenever erysipelas occurs in any part of the body or in the course 
of any other disease. 

In the face, catarrhal and ulcerative processes involving the 
mucous membrane of the mouth, ears, and nose, are often the cause 
of an erysipelas, these processes occurring in a wide range of disor- 
ders from syphilis of the nasal bones to caries of the teeth. Injuries 
of, and surgical operations upon, the scalp not conducted with anti- 
septic precautions, and the common piercing of the lobe of the ear 
in women and female children for the insertion of ear-rings, may be 
followed by the appearance of the disease upon the scalp, as a result 
of which the hair often falls. Fistulas, vaccination, lesions of the 
tender umbilicus of the newly born infant, and railroad accidents 
may be named as common causes of the disease in other regions. 

Predisposing causes of this disease are to be sought for in cachexia, 
epidemic influences, traumatism, violation of hygienic rules, and 
occasionally, the recurrence of previous attacks. Besides these, it is 
alleged that constitutional predisposition and particular articles of 
diet may be responsible for the disease (mussels). 

If the malady be invariably the result of infection due to the pres- 
ence of a micrococcus, the essential cause lies in the specific germ, in 
the absence of which none of the predisposing causes named can be 
effective. It is clear, however that the predisposing causes suggested 
are those in which the multiplication of such germs and their en- 
trance to the general economy are most facilitated. . 

The infectious nature of erysipelas has been demonstrated by 
clinical proof and by the experiments of many observers, including 
Huter, Nepveu, Wahlberg, Lukomsky, Koch, Orth, Fehleisen, 1 and 
others. The micrococci are seen in great abundance, often arranged 
in chains, in the corium, subcutaneous tissue, and lymph spaces of 
erysipelatous skin. 

The streptococcus is a schizomycete which after cultivation in pep- 
tonized meat infusion, produces the disease both in man and the 
lower animals. The cocci multiply in chains whose colonies block 
up the vascular and lymphatic channels and spread beyond the latter 
to the tissues in the neighborhood. The inflammation excited and 
the small cell infiltration which results are directly proportioned to 

1 Die Aetiologie des Erysipelas. Berlin, 1883. 



208 DISEASES OF THE SKIN. 

the abundance of cocci present in any case, whose active multiplica- 
tion is greatest at the border of the erysipelatous patch. The cause of 
spontaneous subsidence of the disease is not wholly clear, but proba- 
bly due to the action of some toxic agent evolved from the tissues. 
Metastasis of the erysipelatous affection is due to the introduction of 
the streptococci to the vascular currents. According to Ziegler there 
is a possibility that the streptococcus of this disease may be related 
to or even identical with those of pus. 

Pathological Anatomy. — Under the microscope, the skin and 
subcutaneous tissues are seen to be infiltrated, the exudate being 
more serous and less rich in protoplasm than that observed in ordi- 
nary phlegmonous inflammation of the skin. The bullae represent 
rapid exudation of this same serosity to the congested epidermis, and 
the elevation of the latter in consequence. The elements of the rete 
and connective tissue are for the same reason swollen, the lymphatic 
and bloodvessels enlarged, and the cutaneous follicles engorged, the 
root- sheaths of the hairs being occasionally separated, necessitating 
thus temporary loss of the pilary growth. In proportion to the 
severity of the exudative process, pus-corpuscles may appear and 
represent, for the most part, degenerative changes in the subcutaneous 
tissues resulting in abscess. The phenomena are, in short, those of 
superficial or deep-spreading dermatitis. After death, the skin 
which has been the seat of the disease cannot be distinguished micro- 
scopically from that of another body. 

Diagnosis. — Erysipelas is to be distinguished from the erythemata, 
from dermatitis of various grades, from eczema, and from scarlatina. 
As a rule, its recognition from all is readily effected, when the 
presence of the fever in erysipelas is had in view, as also the peculiar 
shining, swollen, and rosy-reddish to damask hue of the affected parts. 
The redness is never produced as in scarlatina, by multiplicity of 
reddish puncta, nor is it so widely diffused as in that disease. 
Erysipelas may be at times accompanied by a pruritic sensation, but 
the patch which it affects is never by any possibilty scratched. By 
this simple test alone one may often distinguish an erysipelas of the 
face from an eczema of the same region in a child. From a chronic 
dermatitis with thickening of the affected tissues and redness of the 
surface, erysipelas is to be distinguished by its tendency to spread, 
by its acute career, by its frequent association with bullous or vesicu- 
lar lesions, and by the color, outline, and raised border of the affected 
patch. However, it must be understood that to these localized 
patches of chronic dermatitis several authors have given the name, 
chronic erysipelas, the difference between the views held on this point 
being chiefly one of terms. 

Treatment — Upon the continent of Europe, the therapeutic man- 
agement of erysipelas is in general limited to the employment of such 
systemic and topical measures as are specially required in each case. 
Quinine is administered whenever indicated by the temperature 
record ; and the erysipelatous surface is either left exposed to the 



EKYSIPELAS. 209 

air, covered by dry compresses, moistened by cold or hot aqueous 
lotions, or anointed with unguents, simple, mercurial, or anodyne, as 
suggested in each case. Occasionally cataplasms are applied over 
the inflamed surface. Abscesses, whether subcutaneous or connected 
with a carious tooth, are opened ; the contents of all pustules evacu- 
ated ; and crusts carefully removed. Kaposi lays stress upon freeing 
the nasal cavities of all inflammatory products, whenever the face is 
attacked. 

The method of treating erysipelas by the administration of the 
tincture of iron internally has long been popularized among American 
practitioners. This preparation is given in full doses, from twenty to 
fifty drops, day and night every two to three hours, irrespective of 
the febrile state. When the erysipelatous blush has a distinctly cir- 
cumscribed outline, the annular zone extending for an inch or more 
in width upon the sound and affected skin is either covered with the 
tincture of iodine, pencilled with a crayon of nitrate of silver, or 
painted with a saturated solution of the same salt. This is done 
with a view to limit the extension of the disease. It is true that 
these measures will not always succeed, but it is erroneous to assert 
with some authors that they always fail. Certain it is that, whether 
effective or not in the production of the result, the advancing border 
of the disease will often fail to surpass the limits thus artificially 
described. Collodion has been employed for a similar purpose, 
and Darlin 1 has written in advocacy of the revival of this method 
of treating the disorder, basing its claim on the fact that it dimin- 
ishes the temperature of the part thus protected, and that, by the 
compression excited, it interferes with septic absorption. Heppel 8 
recommends the painting over the surface of a ten per cent, solution 
of carbolic acid in alcohol, as an abortive treatment, for which 
Braithwaite 3 substitutes a similar solution of tannin. 

Excellent results are occasionally reached in the local treatment 
of erysipelas, first by attempting to limit the extension of the disease 
by the application of the tincture of iodine over the peripheral zone ; 
and, secondly, by retaining over the entire surface affected, neatly 
applied compresses saturated with a solution of the hyposulphite of 
sodium in the strength of about one drachm (4.) to the ounce (32.). 
Dr. Spencer, of the United States Army, has frequently seen the dis- 
order upon the face entirely relieved in this way in forty-eight hours. 

With many judicious practitioners all attempts to limit the exten- 
sion of the disease by local applications of an irritating sort (corrosive 
sublimate, nitrate of silver, carbolic acid, tar, turpentine, etc.) are 
condemned as positively injurious. Dry heat is applied by the aid 
of cotton or wool ; or cold compresses are laid over the part ; or iced 
lead lotions with intermissions of application ; or salicylic acid, boric 
acid, iodol, or iodoform, in powder. Resorcin in solution has been 
followed in some cases by excellent results. 

Koch applies one part of creolin, four of iodoform, and ten of 

1 Bull. Gen. de Ther., 1881, vol. ii, p. 239. 

2 Arch, of Derm., April, 1881. 3 Brit. Med. Journ., April 1881. 

14 



210 DISEASES OF THE SKIN. 

lanolin, covered with gutta-percha. Nussbaum uses ichthyol and 
collodion ; or equal parts of ichthyol and vaseline covered with a ten 
per cent, salicylic lint. Hallopeau uses one part to twenty of the 
sodic salicylate upon folds of linen. 

Erysipelas rarely attacks a patient in vigorous health. The large 
majority of all the subjects of the disease are either those who have 
previously suffered from manifest general ill-health, or who have 
been complaining of local ailments, trifling wounds, nasal catarrh, or 
surgical accidents. It is these precedent conditions which often 
demand the special attention of the physician or surgeon. 

It is needless to add that all surgical indications are to be fully 
met when these are present : pus is to be evacuated, crusts removed, 
and drainage secured. The physician and surgeon alike should 
never forget that the disease is infectious, that the patient is to 
be isolated, and to be supplied with an abundance of pure air ; and 
that fomites, surgical instruments, and even the non-disinfected 
hands of the attendants are capable of transmitting the disease. 

Finally, there are forms of erysipelas which are remediless. These 
are usually septic in character. The scarlet blush spreading from an 
irreparable injury of loug duration, is often the last protest of nature 
against the damage which even her final resort of gangrene will not 
avail to repair. 

Prognosis. — Under favorable circumstances, erysipelas, even of 
severe grade and extensive invasion, terminates in complete resolu- 
tion. Reserve should be made, however, in every case, as a serious 
complication has often transformed the simplest into the gravest 
forms of the disease. The very young, the cachectic, the victims of 
drink, the aged, the inmates of hospital wards depressed by other 
illness, and those mentally distressed by destitution and neglect, are 
particularly liable to suffer from grave and fatal forms of the 
malady. 

The patients who fill the beds in most lying-in hospitals are 
young women, either unmarried or deserted by their husbands, and 
unprovided with the necessities of life by those upon whom such a 
responsibility rests. The mental depression thus originating in con- 
nection with the septicemic influences, too common in all large chari- 
ties, is responsible for much of the relation which erysipelas often 
seems to sustain to the puerperal state, as also for the appalling mor- 
tality which it may exhibit under these circumstances. 



THE COCCOGENOUS DEKMATOSES. 211 



The Coccogenous and Bacillogenous Dermatoses. 

A group of disorders differing among themselves are now recog- 
nized as essentially due to the invasion of the skin or its follicles 
with pathogenic cocci and bacilli. The dermatoses next to be con- 
sidered are not occasioned solely by such organisms, nor are all the 
cutaneous affections produced by such a cause here included. Their 
etiological relations, however, are of importance sufficient to justify 
the grouping of those next described. 



[A.] Furunculus. 

Lat., furunculus, a petty knave. 

(Boils.) 

Furunculosis is a disease characterized by the occurrence of one or more circum- 
scribed, cutaneous or subcutaneous abscesses called furuncles, which usually 
terminate by necrosis of tissue in the centre of the phlegmon, its expulsion in 
the form of pus or a core, and a resulting cicatrix. 

Symptoms. — Furuncles, commonly begin as both tender and pain- 
ful indurations in the skin or its subjacent tissues, the summit of 
which soon becomes visible in the epidermis as a reddish punctum. 
It is the result of an active inflammatory process, limited to a defi- 
nite area, and of greatest intensity at the centre of the involved mass. 
This centre is often represented by a hair-follicle, the pustules that 
form subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface, or fairly 
imbedded within or beneath the derma. A yellowish point in the 
centre of the erythematous swelling soon announces the occurrence 
of suppuration. When accidentally or artificially opened at this 
summit, exit is given to a thick yellowish pus which may be com- 
mingled with blood from the traumatism of the neighboring capil- 
laries. The small abscess may then, after discharging its purulent 
contents for a few days, gradually close by granulation, or may also 
expel from its cavity a tenacious, pus-covered, yellowish-green slough, 
known as the " core." This evacuation is usually followed by relief 
of the tense and throbbing pain which is the well-known subjective 
characteristic of the furuncle. 

The length of time requisite for the completion of this process 
varies, with the extent of tissue involved, from a few days to several 
weeks. Boils may occur in any part of the body, but are most 
common about the face, the auricular region, the neck, the armpits, 
the ano-genital region, the hips, the buttocks, the breast, and the 
extremities. They may occur as single or multiple lesions, or may 
succeed each other in crops, especially about the buttocks, trunk, and 
thighs, for a period of several months. It is this succession of boils 
to which the term furunculosis is specially applied. The disease of 



212 DISEASES OF THE SKIN. 

the skin, in such cases, may produce a constitutional effect manifested 
in pyrexia. This is usually encountered when the furuncles are few 
and short-lived, only in individuals of irritable constitution. There 
is also a decided chloro-ansemia due to the pain, fever, purulent drain, 
derangement of the nervous centres, inappetence, and consequent 
perversion of nutrition. 

The sequelae of boils are maculations of a violaceous tint, often 
perceptible in the skin for weeks and even months after their disap- 
pearance ; and cicatrices, pin-head to coin-sized, which are permanent. 

Hydroadenitis, as described by certain French authors, is not 
to be regarded as productive of furuncles, but of benign tumors of 
epithelial type possibly originating in the coil glands. 

Etiology. — The microbe producing boils is the staphylococcus 
pyogenes aureus. The remote cause is, however, often exceedingly 
obscure. It is true that they are encountered in typical subjects of 
diabetes, of the exanthemata, and of " hospitalism," where anaemia, 
asthenia, marasmus, malnutrition, and exhaustion resulting from 
excesses, from grave general disease, from low fevers, and from 
nervous strain, play a prominent part. But the reverse is also true. 

On the other hand, scratching, eczema, scabies, and other cutaneous 
diseases, lice, and external irritants of various sorts are responsible 
for many boils, especially those that are few and not followed by 
similar lesions. When, however, such sequence occurs, it should 
never be forgotten that the furuncles, if sufficiently numerous and 
large, are amply capable of disturbing the general economy. The 
collar-button at the back of the neck ; the edges of an unyielding 
corset, for one unaccustomed to it; a hard bench; the saddle-tree; 
and many similar articles, may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. g., by dyers, lead manufacturers, etc. 

Lastly, it is exceedingly common for patients thus affected to apply 
to practitioners for remedies intended to " purify the blood f and, 
inasmuch as the iodide of potassium is often mischievously prescribed 
in response to this demand, the original trouble is thus enhanced to 
a manifold extent. Many cases of furunculosis are instances of boils 
resulting originally from external irritation, which have greatly mul- 
tiplied and finally profoundly affected the system under the impulse 
of the so-called " blood-purifying " process. 

Pathology. — Authors have attempted to explain the phenomena of 
furuncle by supposing the process to be due to inflammation attack- 
ing a sebaceous follicle in the derma ; or a pilary follicle or sweat- 
gland beneath the skin ; or the peri-follicular tissues , or the con- 
nective tissue pedicle which passes downward from the fundus of the 
hair-follicle to the subcutaneous tissue ; or the blood and lymphatic 
vessels which surround the sac. It is reasonable to suppose that they 
are all in the right. No one of these component parts of the skin is 



THE COCCOGENOUS DERMATOSES. 213 

known to be exempt from the changes which are induced by the inflam- 
matory process. It is difficult to discover in the furuncular lesion 
any symptoms which set it apart from the other results of localized 
inflammation, its phenomena differing from those of ecthyma, acne, 
pustular eczema, anthrax, etc., only by the seat and extent of the 
inflammation. The core of the furuncle represents a necrosis in- 
duced by the violence of the exudation, and so does the gangrenous 
slough which falls after a severe dermatitis calorica. The core of 
the furuncle is moist, yellowish, and puriform, because it is com- 
pletely immeshed beneath the epidermis, and pus-soaked. The core 
or slough of a gangrenous dermatitis may be as dry as a crust, from 
desiccation in consequence of exposure to the air, or be in various 
degrees moistened by the fluids escaping from the tissues beneath. 
Where there is no core in furunculus, this absence is probably due 
to the fact that the purulent products of the inflammation pass with 
readiness from the peripheral to the central parts of the phlegmon 
without having to leak through or between, or to be pressed against, 
masses of centrally disposed elements, whose vitality is thus the 
more readily lost. Inflammation of tissue in a practically closed 
chamber, under tense pressure, under slight pressure, exposed freely 
to the air, or in all grades protected from it, will always differ in its 
phenomena. It is wiser to attribute these differences to the circum- 
stances under which it is displayed than to any peculiarities in the 
nature of the process itself. 

The contagious character and parasitic origin of furuncles have 
been studied by a number of observers. Gingeot, 1 Startin, Trastour, 
Lowenberg, Pick, Pasteur, and others have, with varying success, 
reproduced these lesions by experimental inoculation. The name 
torula pyogenica has been given to a vegetable parasite recognized in 
furuncular products, which, however, in development, is to a marked 
degree modified by the nature of the site in which it is implanted. 

It is with these demonstrations in view that Giug&ot suggests the 
employment of parasiticides in the treatment of furunculosis, the 
acid nitrate of mercury, iodine in tincture, carbolic acid, and borated 
alcohol. Internally sulphur and the hyposulphite of sodium in large 
dilution are administered. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
exaggerated symptoms of the latter, described elsewhere. Circum- 
scribed furuncular abscesses of the groins and axillse are not to be 
confounded with suppurating, sympathetic, or virulent buboes of 
these regions, associated with genital or extra-genital, contagious, 
venereal sores. This goes without saying ; but many such errors 
have been made. Furuncles of the anal and genital region may be 
significant of surgical affections of the neighboring parts (perineal, 
peri-prostatic, peri-urethral, and scrotal abscesses in men ; suppura- 
tion of the vulvo-vaginal gland in women, etc.). 

Treatment. — The debilitated constitution of many patients affected 
with boils indicates clearly the need of atonic regimen, including the 

1 Bulletin gen de Tkerap., Jan., Feb., and Mar. 1885. 



214 DISEASES OF THE SKIN". 

administration of iron, quinine, and strychnine, the mineral acids, 
and, contrary to the generally accepted opinion of the laity, a gene- 
rous diet of milk, cream, eggs, and fresh meats. To these, wines 
and malt liquors may be at times added with advantage. Change of 
climate, of diet, of cooks, and of the habits of life is most service- 
able in cases of prolonged furunculosis. The mineral waters, at 
some of our health resorts, prove especially valuable for the debility 
which often results from these disorders. The urine should always 
be examined for sugar, albumen, and an excess of urates. The 
internal remedies which possess reputation in this complaint are ar- 
senic, sulphur, and the sodic sulphites, the alkalies, tar, fresh yeast, 
in tablespoonful doses, phosphorus, and the syrup of the hypophos- 
phites of lime, iron, soda, and potassa, and the sulphide of calcium. 

The last-named is probably more highly esteemed by the larger 
number of practitioners than all other internal remedies, and is 
given in doses of one-fifth to one-tenth of a grain (0.0133-0.0066) 
every three or four hours in the day. In lithsemia, the acetate or 
citrate of potassium is given in large dilution or the liquor potassa?; 
in gouty states, colchicum and the alkalies, including the sodic salicy- 
late. No one of these articles, however, may be described as an 
efficient and certain remedy for the complaint ; many cases will pro- 
gress without hindrance from any or all of them. 

Attempts in the direction of aborting a furuncle by the topical ap- 
plication of the stronger alkalies (aqua arnmonise) or acids ; caustics 
or cautery, ice, or premature complete incision with the scalpel occa- 
sionally succeed ; more often they fail. 

The best methods of local treatment are the simplest. The part 
may be frequently bathed in a hot, saturated solution of boric acid ; 
and immediately after covered with lint thickly spread with a paste 
form of two drachms each of the zinc oxide and powdered starch to 
the half ounce of vaseline ; or with a freshly made benzoinated zinc 
ointment. Where the pain is unusually intense, the parts may be 
covered with hot borated lotions covered with protective. When the 
pus is evacuated and the slough wholly or in part detached, the 
dressings for most cases are after washing with the hot borated lotion, 
boric acid in powder, iodol, iodoform (objectionable on account of its 
odor), aristol, or hydronaphthol one part to one-hundred of one of 
the former articles. 

Violent squeezing of a furuncle in order to separate its slough or to 
evacuate its contents should never be practised. 

Prognosis. — The future of the patient affected with a prolonged 
furunculosis is that only of which there can be question. Eventually 
the worst cases are relieved when unaccompanied by systemic or 
visceral disorders, and where the circumstances of the sufferer permit 
him to pursue the most advantageous course (travel, diet, abstraction 
from business, etc.). The resulting cicatrices depend upon the 
severity of the process. Often they are small, and in the course of 
years scarcely distinguishable. In exceptional cases they are large, 
persistent, and disfiguring. 



Anthrax is a term which has been applied, not without some confusion in the 
past, to two affections here separately considered. 



THE COCCOGENOUS DERMATOSES. 215 

[B.] Anthrax. 

Gr., avdpai;, a live coal. 



1. Anthrax Simplex. (Carbunculus, carbuncle.) 

Anthrax Simplex is a circumscribed, cutaneous, and subcutaneous 
abscess, usually larger than a furuncle, due to the pressure of 
staphylococci, characterized by dense induration and sloughing, 
and terminating, in favorable cases, by the production of a per- 
sistent cicatrix. 

Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the 
site of the lesion. In cases where the anthrax is formidable and 
seated upon or near the head, alarming symptoms of prostration, 
stupor, somnolence, and even coma, may be noted. With and with- 
out these concomitants, a dense, dull-red, indurated, and painful 
phlegmon soon appears, varying in size from a small hen's-egg to an 
orange, and even much larger, involving not only the skin, but the 
tissues beneath. Suppuration finally occurs ; but the pus is not con- 
fined to a single sac. It undermines the integument, and often, 
through several apertures, leaks out indolently to the free surface. 
The fenestrated or cribriform appearance of the skin covering the 
carbuncle constitutes, in this stage, one of its most striking features. 
Through these apertures may be distinguished the whitish or yel- 
lowish pus-soaked sloughs, or portions of a single slough, which can 
be at times extracted through the orifice. Often the entire mass sepa- 
rates in a single slough, involving the skin and subcutaneous tissues, 
leaving a crateriform ulcer of formidable size, which, in favorable 
cases, proceeds to heal by granulation. The resulting cicatrix is at first 
of a deep violaceous tint, and later becomes blanched. It is indelible. 

The fever which usually accompanies this process may be mild or 
severe, or, more commonly in dangerous cases, of a typhoid character. 
It results unquestionably from sepsis due to unliberated pus and 
necrotic tissue, and is naturally most grave in consequences where 
the patients are weakened by previous asthenic disorders. Under 
these unfavorable circumstances, the carbuncle may spread at the 
periphery, with islands of necrotic tissue and ill-conditioned pus sep- 
arated by bridges of empurpled, infiltrated, and yielding skin. 

The peculiar lesions of this disease most often appear upon the 
back of the neck, the back of the trunk, and the lateral aspect of 
the hips and thighs, usually in a single development, though occasion- 
ally two or even three carbuncles of small or medium size may co- 
exist. The reason for their appearance in the localities named is 
clear. It is here that the skin is most thick and resisting, and, as a 
consequence, purulent foci when formed are covered in by the most 
voluminous layers of the connective tissue of the corium. 



216 



DISEASES OF THE SKIN. 



Etiology. — Anthrax simplex is produced by the obscure causes to 
which reference has already been made as probably effective in the 
production of boils. The two may coexist ; or the one follow the 
other ; and intermediate forms occur which might be assigned to 
either class. The disease is encountered more often in men than in 
women, and in later than in earlier life, simply because the tissues 
constituting its sites of preference offer in these individuals, and at 
these ages, a greater resistance to the exit of pus. The pus cocci 
may sustain an etiological or purely accidental relation to the lesion. 
It is at times an epiphenomeuon in cachexia, diabetes, albuminuria, 
syphilis, pemphigus, and exfoliative dermatitis. 

Fig. 42. 




Vertical section of anthrax. Dense network of fibrous bundles, with interspaces communicat- 
ing and extending to the subcutaneous tissue. (After Warren.) 



Fig 




Section of anthrax. Infiltrated papillse are seen at I, distended in .balloon-shaped figures, 
between which the rete is compressed ; at p and mp columnse adiposse are seen ; /, division of 
elements, the fibrous bundles resolving into protoplasm. (After Warren.) 

Pathology. — The pathological anatomy of carbuncle is well de- 
scribed by Warren, 1 whose observations conclusively show that the 
inflammatory process here is one with that seen in the simplest 
pustule. The peculiar symptoms of carbuncle are due solely to the 
formation of the phlegmon beneath the dense and extremely thick 
masses of fibrous tissue found in the back " for the protection of 



The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. 



THE COCCOGENOUS DERMATOSES. 217 

that comparatively defenceless portion of the body." The elements, 
multiplying with the intensity of the inflammatory process, first in 
the subcutaneous adipose tissue, pass upward along the fat columns 
described by Warren as columnar adipose, crowd these, push along 
their horizontal clefts branching from either side, infiltrating the 
derma, pass along the edges of the hair-follicles, fill the papillae till 
the latter "balloon " with pus, ooze to the surface through the cribri- 
form apertures in the undermined epidermis, and soak the bundles 
of fibrous tissue, relatively intact, which constitute the undetached 
mass of sloughing tissue. 

The general symptoms in anthrax, pyseinie, septicemic, sympathetic, 
are due solely to pus imprisonment. The pus formation is due to the 
presence of the staphylococcus pyogenes aureus and the toxine it 
produces. Back of all lies the favorable soil (in the diabetic, the 
cachectic, etc.) for multiplication of these micro-organisms. 

Diagnosis. — It follows from what has preceded that carbuncle and 
furuncle differ solely in consequence of the depth of the starting- 
point of the phlegmou, and the density and resisting power of over- 
lying tissue. The former is therefore flatter, denser, less rapidly de- 
veloped, larger, less tender, and more painful, opens by many rather 
than by one or two apertures, and is followed by larger sloughs, 
ulcers, and cicatrices, and occasionally by fatal results. 

Treatment. — Crucial and other deep incisions in the local treat- 
ment of carbuncle are certainly inferior in results to the method 
advocated by Wood l and Talor, 2 which is employed in cases with 
complete success. A saturated solution of pure carbolic acid is 
injected through the several apertures in every direction into the 
sloughing tissues by the aid of an hypodermatic syringe. When the 
orifices are not sufficiently numerous, the point of the needle is thrust 
through the thinned integument at the summit of the swelling in 
several points. The pain is severe, but short-lived ; the tissues are 
blanched, indurated, and destroyed ; the slough in a few days is 
readily separated after division of its slender fibrous attachments ; 
and the ulcer rapidly contracts with the sequel of a smaller scar. It 
is necessary to use pure acid in saturated solution to prevent absorp- 
tion of the injected fluid and resulting toxic effects. 

Relief is afforded in many cases by hot borated lotions and fomen- 
tations, with the requisite skill in the surgical dressing of the parts 
by carbolated lotions, extraction of the slough wholly or in portions 
by the forceps, and the subsequent employment of boric acid, iodol, 
iodoform, aristol, or the paste recommended in the treatment of 
furuncles. An excellent method of withdrawing the purulent and 
sloughing contents of the carbuncle is to apply over it, at the proper 
period, an exhausted receiver, such as a common cupping-glass. 

Erasion of the entire abscess with the curette, and subsequent 
antiseptic dressing is the best radical measure of relief. 

In many cases the antiseptic treatment of a carbuncle furnishes 

1 Toledo Medical and Surgical Journal, Dec. 1880. 

2 Austral. Medical Gazette, Dec. 1, 1881. 



218 DISEASES OF THE SKIN. 

decidedly the best results as regards the comfort of the patient and 
limitation of the disease. Here there is absolutely no surgical inter- 
ference with the lesion, beyond the incisions made for the evacuation 
of pus. Violent squeezing and manipulation of the carbuncle are 
interdicted. It is freely powdered with boric acid, iodol, or iodoform, 
and on it is laid soft, felt cloth, thickly spread with any emollient 
and antiseptic salve. Bulkley 1 advises the use of the ordinary zinc 
salve for this purpose. Boric acid in powder, or iodol, thickly 
dusted over the carbuncle and covered with antiseptic wool will also 
be found a useful dressing. 

Internally calx sulphurata should be administered in full doses. 
it has an unquestionable effect in diminishing the pus-formation. 

Other constitutional treatment is that demanded in the case of 
furunculosis, including the liberal employment of tonics, a generous 
diet, a strict observance of the rules of hygiene, and stimulants 
when indicated. Pyrexic, septicemic, pysemic, and adynamic states 
require the special management of such complications, including cold 
sponging of the surface in fever, and the use of quinine and stimu- 
lants, with artificially applied heat in the algid condition. The urine 
should always be examined for sugar and albumin. 

Prognosis. — A serious issue need be anticipated only when the 
complications described above are grave in character, or occur in 
asthenic constitutions. 

2. Anthrax Maligna (Malignant pustule, Fr., pustule maligue, 
Charbon). 

Anthrax Maligna is a carbuncular lesion resulting from infection 
of the skin or another organ of the body, with a virus containing the 
anthrax bacillus, furnished by some animal infected with splenic fever. 

This disease in man is fortunately rare of occurrence, and is 
usually derived from some animal affected with the specific malady 
variously termed "Anthrax," " Charbon," " Splenic Fever," "Splenic 
Apoplexy," or " Texas Fever." The lesion under consideration is 
also termed Splenic Fever Carbuncle. After inoculation with the 
disease from any infected animal, the human subject may (a) perish 
from systemic poisoning wholly septicemic in character with few 
external symptoms ; or, (b) when life is sufficiently prolonged, suffer 
from visceral symptoms, and exhibit subcutaneous tumors ; or (c) 
exhibit the symptoms of the disease now under consideration. 

In from twelve to eighteen hours after inoculation a painless 
macule is first manifested, usually upon the dorsum or other parts 
of the hands or face to which the virus has had access. This is 
followed by an inflammatory and pruritic papule, which is rapidly 
transformed into a flaccid vesicle filled with a bloody serum and sur- 
mounting a firm indurated " nucleus," or a larger blood-filled bleb 
reposing upon a somewhat painful, engorged, and often densely in- 
durated base involving extensively the subcutaneous tissue. One or 
more similar lesions may follow in the surrounding integument, 

1 Journ. of the Amer. Med. Assoc, May 16, 1885. 



THE COCCOQENOUS DERMATOSES. 219 

coalescence of which produces a large, angry, oedematous, and often 
gangrenous ulcer. The involved skin may be as large as a small 
coin, or of the size of the palm of the hand. The lymphatic vessels 
and ganglia enlarge, and often suppurate ; metastatic abscesses form ; 
and the constitutional symptoms supervening are those described in 
conuection with equinia. 

If recovery ensues, the gangrenous mass is sloughed off as in 
favorable cases of carbuncle ; if the result is to be fatal, the process 
is rapidly aggravated by oedematous infiltration extending to a wider 
area and by larger quantities of tissue falling into necrosis. 

In some cases the accompanying fever is high, with marked 
delirium ; in others, it is of a typhoid character. Death results from 
shock, septicaemia, or exhaustion, though in cases where the lesion is 
circumscribed and unattended by constitutional symptoms, recovery 
may ensue. 1 

Etiology. — The disease is induced by infection from one of the lower 
animals, usually horned cattle, who suffer from charbon or splenic 
fever, and are in relation to herders, ranchmen, etc. The susceptibility 
of the carnivora to the disease is very much less than that of the her- 
bivora. It is claimed that not only direct inoculation may produce 
the disease, but that it may be extended by the medium of flies and 
other insects. More recently it is claimed that food, drink, and even 
inspired air may be the medium by which the disease is conveyed. 

Pathology. — Since the first investigations reported by Davaine to 
the French Academy in 1864, Pasteur, Klebs, Koch, Carnevin, and 
others have fully demonstrated that splenic fever is solely due to the 
multiplication in the blood and tissues of a rod-shaped bacillus, the 
bacillus anthracis, which is always motionless. Under culture the 
bacilli may develop long filaments, many times larger than the 
original rods, with a distinct sheath about a protoplasmic cylinder, 
which after segmentation furnishes oval and shining spores. These 
have been cultivated again and again, with re- 
sulting germs that have produced the disease FlG - 44 - 
artificially in the lower animals. i 

The pathological anatomy of the malignant g^ <$ 

pustule is that of carbuncle with the added 5* ********* 

fact that specific bacilli and spores are abun- ^^ /#^» ftt 
dantly present in the blood and debris of ( #) " / 

tissue. _ . y^^ ^#* 

In establishing a diagnosis, care must be xS^m^ JSS^ 
taken to avoid one source of error. Malig- #" fc 

nant pustule in man is not of frequent occur- 

. ,-i . i . • n • Malignant pustule bacilli 

rence in this country, but occasionally various and pus CO rpuscies. 
cutaneous eruptions are induced upon the hands, About x 300. 

after contact with animals or hides upon w r hich 

chemical solutions have been applied for the destruction of lice. 
These solutions usually contain arsenic, corrosive sublimate, or other 

1 A chromo-lithograpb exhibiting the peculiar features of the malignant pustule in the neck, 
will be found in the British Med. Journ. of June 13, 1834, illustrating a paper by Mr. Morrant 
Baker. 



220 DISEASES OF THE SKIN. 

substances capable of exciting a localized dermatitis. Chancre of 
the face, severe anthrax simplex (carbuncle), and poisoned wounds, 
are all differentiated by their relatively indolent course and the ab- 
sence of gangrene. 

The treatment is to be conducted on the principles of general thera- 
peutics. Popper/ an Hungarian physician with a large experience 
in malignant pustule, reports success by deep excision of the lesion, 
extending the operation to the subcutaneous connective tissue. This 
has always proved successful when practised before the occurrence of 
general symptoms. 

A number of other authors have had successful results after ex- 
cision. Pitts, for example {Brit. Med. Journ., March 19, 1887), 
reports two successful excisions of malignant pustule in the case of 
brothers. Johnson, of New York, and Robinson, of England, each 
reported in 1892 successful results after excision. Hebra was not 
in favor of the early cauterization of the malignant pustule, and it 
may be considered as a questionable method of procedure. 

A grave case of malignant pustule is recorded, 2 in which recovery 
ensued after the hypodermatic injection of the tincture of iodine. 
Three syringefuls of the pure tincture were deposited beneath the 
skin at the periphery of the diseased surface, and lint soaked in the 
same was applied over the slough. Internally, fourteen drops of the 
tincture (1.) with three grains (0.26) of the iodide of potassium, were 
also administered. Normal cicatrization followed in this and six 
other cases recorded. 

Crucial incisions with the free application afterward of pure car- 
bolic acid have been followed by good results. Mr. Baker, of Lon- 
don, reports rapid and complete relief after excision and the free use 
of iodoform. Internally, the hyposulphite of sodium and quinine 
are successfully employed. The febrile, typhoid, and adynamic 
features of the disease are to be treated in accordance with the recog- 
nized principles of general medicine. 

Prognosis. — The disease proves fatal in about one-third of all cases. 
Early excision in a healthy subject gives promise of satisfactory 
results. 

[C] Equinia. 

Lat., equus, a horse. 

(Glanders, Farcy. Fr., Morve, Farcin. Ger., Rotzkrankheit, 

Maliasmus.) 

Equinia is a contagious, virulent, and inoculable disease, transmitted to man from 
the horse, mule, or ass, and produced by a bacillus resembling that of tubercu- 
losis. 

Symptoms. — The acute form of the disease commonly follows a 
period of malaise lasting a few hours or as many weeks, in which the 

i Centralbl. f. Chir., 1881, No. 33. 2 Arch. gen. de Med., Feb. 1883. 



THE COCCOGENOUS DEKMATOSES. 221 

patieDt complains of vague pains of a rheumatoid type, followed by 
thermal variations. The temperature rises rapidly to a point of 
danger, with chills, fever, diarrhoea (often following constipation), 
and rapid exhaustion, the picture being nearly that of acute septi- 
caemia. 

The cutaneous symptoms begin often with an erysipelatoid blush, 
the surface, affected and swollen, also producing papules, vesicles, 
pustules, and bullae, with dense but ill-defined induration of the sub- 
cutaneous tissue ; or reddish and yellowish papules appear, which, as 
in the case of the fluid-containing lesions, coalesce and furnish a 
bloody discharge. A more or less rapidly occurring sloughing 
ensues, sometimes with extensive gangrene, though the patient often 
succumbs before the culmination of the morbid process. The lym- 
phatic vessels are swollen and well defined, often indurated. These 
symptoms affect chiefly the face, hands, feet, and other exposed parts 
of the body. There is often a sanious or purulent and offensive 
catarrh from the nostrils, the mouth, and the eyes, the inflammatory 
process spreading rapidly to the deeper mucous surfaces. This 
catarrh, chiefly nasal in site and declared conspicuously by the nasal 
voice, due to the blocking up of the nose by the viscid, foul-smelling, 
and haemorrhagic discharge, is one of the most characteristic features 
of the malady, and of importance in the diagnosis. 

In the chronic form of the disease this nasal catarrh is less con- 
spicuous at the outset, though it may be later a prominent feature of 
the malady. A few days or weeks after infection, pustules, as in 
the acute form, resembling those of variola, but flattened and never 
umbilicated, begin as vesicles or even papules, coalesce to bullae, 
occur in successive crops, and run on to the production of multiple 
abscesses, poorly defined on the extremities and about the face ; much 
more rarely on the trunk. These may be of phlegmonous type, 
or be deep, brawny infiltrations with purulent foci, extending over 
months of invasion and decline of the disease. From these abscesses, 
pea- to nut-sized over the face, larger on the limbs, flows an 
abundant, sanious, semi-liquid, or viscid, yellowish, and offensive pus. 
Ulcers form at many points, with purplish borders, oval or roundish 
contour, and thin edges suggesting the appearance of the scrofulous 
ulcer of classical type. The edges may be softish or indurated. By 
their multiplication or coalescence the lips, nose, lids, and other parts 
of the face may be in part or wholly destroyed. The disease may 
steadily advance, or may seem to be arrested for a time and reawaken 
to activity. Meantime the lymphatic glands are either unchanged or 
enlarged by sympathy. In the course of months or years there is a 
fatal issue. The disease is fortunately rare. 

Etiology and Pathology. — The disease is almost invariably pro- 
duced by infection from horses, a history of contact with such ani- 
mals being one of the important points in establishing a diagnosis. 
The infection is produced by the glanders bacillus (Weichselbaum, 
Schiitz, Loeffler, Bouchard). They have nearly the size of the 
tubercle bacillus, being cultivated and capable of producing the dis- 



222 DISEASES OF THE SKIN. 

ease in the lower animals after injection of cultures. They are found 
in the greatest abundance in papules, abscesses, blood, and brain 
tissues of the diseased. 

The treatment is that of the septic condition, and is of little avail. 
The prognosis is in the highest degree grave. 

Pustules from Cadaveric Infection. — In a number of lesions 
recognized especially upon the fingers and hands of those in contact 
with the bodies of the dead, tubercle bacilli have been recognized. 
Such lesions are the verruca necrogenica described in the chapter on 
tuberculosis cutis. Other lesions, however, generally known as dissec- 
tion-wounds, occur with symptoms of acute poisoning upon the hands 
of those exposed to the danger of post-mortem examinations and dis- 
sections. At the point of inoculation, which may be either the site 
of a former abrasion, rent, or the mouth of an open follicle, a painful 
vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla 
rises rapidly from an angry and indurated base, with hypersemic 
areola in dull red shades. Suppuration, crusting, or ulceration may 
follow, limited to the seat of the lesion; or lymphangitis in various 
grades with consequent pysemic or septicemic involvement of the 
system. Suppurative and non-suppurative axillary buboes are 
common. Gangrene and necrosis of the soft parts and bones, especi- 
ally the phalanges, may ensue, as also a fatal result from the systemic 
disorders named. In a few cases a chronic marasmus is induced. 
Prophylaxis, by proper protection of the hands and the immediate 
cleansing and disinfection of any accidentally wounded point, is of 
the highest importance. The treatment is to be conducted in accord- 
ance with the principles already described. 

There is reason to believe that accidents of this kind may be pro- 
duced by absorption of the alkaloids engendered in the cadaver by the 
decomposition of proteid substances, called ptomaines. These were 
first isolated and named by the late Professor Selmi, of Bologna, 
subsequent investigation seeming to prove that in chemical constitu- 
tion they do not differ from the alkaloids produced by albuminous 
decomposition in vegetables. Brieger has identified neuridine, cada- 
verine, putrescene, and saprine in the dead body, and, with these a 
peculiarly toxic alkaloid to which he has given the name mydale'in. 
All these are capable, after ingestion or admission by other avenues 
to the circulation, of inducing salivation, vomiting, diarrhoea, dysp- 
noea, paralysis, and death. The lethal issue in the case of lesions of 
the character here designated, is probably due to the fact that, at the 
site of the pustule of irritation or traumatism, one or more of these 
toxic alkaloids has gained admission to the lymphatic circulation. 

Pustules and Other Lesions resulting from Wounds In- 
flicted by Keptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites and stings of 
flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, 
however, serious and even fatal consequences have been recorded. 






THE COCCOGENOUS DERMATOSES. 223 



The wounds produced by the tarantula and scorpion (which frequently 
lurk in the clusters of tropical fruits now imported to almost every 
part of this country), as also of the venemous reptiles, may prove to 
be grave. Urticarial, vesicular, pustular, papular, bullous, and 
petechial lesions may thus originate and be the cause of a more or 
less severe dermatitis with toxic symptoms. In the latter event, it is 
common in this country to administer as remedial agents, alcoholic 
stimulants as freely as they can be ingested. 

[D.] Delhi Boil, Aleppo Evil, Biskra Bouton, Oriental Boil, 
Gafsa Button, Natal Sore. Fk., Clou de Biskra. 

This is a chronic endemic disorder characterized by the occurrence 
of painful nodosities upon the face, hands, and other portions of the 
body. The lesions are one or multiple papules, pea- to bean-sized, 
which subsequently become purulent and ulcerate indolently, or be- 
come covered with scales. They are often grouped in patches aud 
followed by cicatrices. The exact nature of the malady thus named, 
is unknown. It is quite fully described by Fox, Farquhar, Pollack, 
Willemin, and other authors, as occurring in India, the region about 
the Euphrates and Tigris Rivers, and along the northern coast of 
Africa, especially Algeria and Morocco. • The descriptions given 
suggest that, in some instances at least, several different disorders 
have been included under these titles, such as the lesions of lupus, 
syphilis, and the frequently formidable symptoms produced in the 
skin by the vegetable parasites in tropical countries. 

Laveran 1 has lately described afresh the Biskra bouton. It occurs 
not only in Biskra but also in the adjoining oasis. It shows itself 
as an endemic only in the months of September and October, and 
continues until December. Xo new cases appear in January and 
February. All ages, both sexes, the strong and weak, are liable to 
it. The eruption affects the face and extremities by preference, 
sometimes also the trunk. It ordinarily attacks the same person 
but once, yet may recur. So long as the disease prevails, the least 
excoriation has a tendency to become Biskra button. At first there 
is a reddish, painless, elevation of the skin, the size of a pin's head ; 
the centre of this soon dries and a brownish crust forms, easily re- 
movable. Beneath this there is a small round ulcer. The papules 
may occur in patches, bearing thick crusts which long resist. The 
crusts are remarkably dry. When the latter are removed and the 
ulcer left undressed, a new, less firm crust forms ; when dressed, the 
crust-formation is prevented and an ulcer of an obstinate character 
remains, which in the leg is not unlike a varicose ulcer. If the 
original crusts be not disturbed, these eventually fall and leave no 
scar. Should, on the contrary, the crust be removed at the begin- 
ning of cicatrization, this is accomplished slowly and a permanent 
scar remains. Lymphangitis, erysipelas, and phlebitis, occur as 
complications. There are no peculiarities in the crusts. Epidermic 

1 Annal. de Derm, et de Syph., 1881, t. i. p. 173. 



224 DISEASES OF THE SKIN". 

cells, pus corpuscles, aud bacteria, are commonly recognized by the 
microscope. An expectant treatment is the best. Should the crusts 
be removed or fall off it is advisable to powder the ulcer with henna, 
which favors the production of fresh crusts and cicatrization. As 
regards its pathogenesis, the author holds Weber's view, that the 
disease is contagious and inoculable, and perhaps auto-inoculable. 
The virus exists in the crusts, but its nature is not established. 
Carter's opinion as to its parasitic nature is not tenable. 

Dr. Altounyan, of Turkey, 1 protests against the view, given above, 
entertained by Geber and others, that the Aleppo button is a term 
applied indefinitely to various cutaneous disorders. In his view it 
is a specific disease beginning, independently of the hair-follicles, as 
a small acne-form papule, disappearing on pressure and pinkish in 
color. Afterward it grows deeper, larger, and harder, and becomes 
more adherent and more vascular. Still it is livid, sensitive, smooth, 
and boggy to the touch. Pus forms centrally and dries into grayish- 
brown crusts which are rupioid in character. Beneath is a spongy 
ulcer, with ragged margin, ovoid contour, and ichorous discharge. 
Healing is by the production of a permanent and deforming scar, the 
entire course of the disease lasting one year. 

Dr. G. B>. Eliott, of New York, who made a microscopical exami- 
nation of some specimens' furnished him by Altounyan, reports that 
the disease was limited to the epidermis and corium and its area, 
occupied by small round inflammatory or formative cells and 
epithelial elements. There was a distinct line of separation between 
the healthy and diseased tissue. No cryptogamous or other micro- 
organisms were recognized. The hair-follicles and other glandular 
structures were intact. 

Altounyan found the best treatment to be the painting of the 
button with the tinctnre of iodine ; and that one attack furnished 
immunity against a second. He believes the disease to result from 
the bite or sting of an insect. 

Phagedena Tropica. (Aden ulcer ; Malabar ulcer.) 
Hirsch, Parke, and others describe a condition peculiar to trav- 
ellers in tropical countries, rarely in temperate zones, attacking those 
particularly Avho have been exhausted by fatigue, malaria, and mal- 
nutrition. In these cases a slight traumatism becomes later the seat 
of a vesicle or bleb from which as a centre spreads a rapidly 
phagedenic sore extending by sloughs through skin, muscle, tendon, 
and bone. The disorder is usually first noticed on the exposed 
parts of the lower limbs, but other regions may be earliest involved. 
In mild cases there is arrest of the process before severe destruction 
is accomplished, and then cicatrization follows. 

The disease occurs chiefly among the natives of the tropics, but 
also attacks travellers. It is aggravated by all unfavorable climatic 
and individual conditions. Microbes have been discovered, supposed 

1 Journ. of Cutan. and Ven. Dis., viii., No 6, June, 1885. 



THE COCCOGENOUS DERMATOSES. 225 

to be pathogenic, by Boinet, who has also cultivated the same and 
produced successful inoculations of animals. 

The treatment is precisely that employed for all similar surgical 
emergencies, viz., support by proper food and medicines ; locally, 
antisepsis and parasiticides. The caustics employed by the French 
are inferior to effective parasiticides, such as the bora ted, salicylated, 
and sublimate dressings. 

[E.] Phlegmona Diffusa. 

Gr., <p?\,e-y/j,ovTj } an inflamed tumor. 

Phlegmona Diffusa is a grave form of non-circumscribed inflammation of the 
skin, in which the integument becomes livid, hot, swollen, painful, and tap 
for necrosis, this process occurring in one or many places to a considerable 
depth, and accompanied by fever and systemic disturbance. 

The word phlegmon is employed by most English and American 
writers to indicate a circumscribed inflammation of the skin, ter- 
minating naturally in suppuration, and, as to the tissues involved, 
larger than an ecthymatous pustule, and yet not large enough to be 
termed an abscess. Circumscribed phlegmons are represented by 
most furuncles, and, at one stage certainly of their career, also by 
carbuncles. 

In the disorder, however, under consideration the symptoms, both 
local and general, are far more serious. The first evidence of trouble 
may be a severe chill, followed by high fever and deep-seated ham- 
mering pain, felt in the part which is the seat of the disease. This 
is soon recognized as an cedematous area, of dull red or livid hue, 
tensely infiltrated, of the familiar brawny type and indeterminate 
outline. All of these symptoms rapidly increase as resolution is very 
rarely attained, and are followed by suppuration at one or more 
points. In diffuse phlegmon, however, the brawny tenseness of the 
inflamed skin has been so great that vascular thrombosis occurs and 
the circulation is greatly impeded, as a consequence, between the 
points where pus forms, or about a single point. The tissues then 
become more or less necrotic, both during and after the formation 
and evacuation of pus. 

The fever meantime may abate or entirely remit, or, in grave 
cases, steadily persist. In the latter event, the subcutaneous tissue, 
fascia, periosteum, bones, joints, and ligaments may be involved. 
But in all favorable cases the systemic condition is greatly improved 
when pus is no longer deeply or extensively formed, and when the 
gangrenous shreds and sloughs are well loosened or entirely removed. 

The " Acute Purulent (Edema " of English authors, and the Gan- 
grene Foudroyante of the French may be regarded as severe types of 
diffuse phlegmon. In most of such cases the patients die septicemic 
before the complete evolution of the cutaneous inflammation has been 
reached. In others, the affected part, suddenly losing its tense 
brawny hardness, becomes emphysematous, or crepitates with bubbles 

15 



226 DISEASES OF THE SKIN. 

of gas produced by decomposition. The patient may then become 
somnolent or delirious, or be the victim of an intercurrent and fatal 
involvement of the kidneys, lungs, liver, spleen, or bowels. 

The treatment of diffuse phlegmon is largely surgical, and in this 
day simple. Incision, drainage, and disinfection, are the three essen- 
tial requirements. These thoroughly assured, the systemic treatment 
is by quinine, stimulants, when indicated, and the accepted remedies 
for the typhoid condition generally, including rest in the recumbent 
posture and a proper supply of wholesome air and food. Amputation 
of limbs may be necessitated in order to save life. 

The prognosis rests almost entirely upon the extent, diffusion, and 
severity of the local inflammation, and the systemic condition of the 
patient. In a previously healthy subject, with good hygienic 
environment and the absence of thrombosis, pyaemia, septicaemia, and 
erysipelas, the results w 7 ill generally be favorable. With the reverse 
of these conditions, the outcome may be serious as regards the loss 
of a limb, deformity, or a fatal issue. 

[F.] Sycosis. 

Gr., gvkov, a fig. 

("Non-parasitic" Sycosis; Mentagra; Ficosis ; Folliculitis Barbae. 
Gee., Bartfinne.) 

Sycosis is an acute or chronic inflammatory affection of the surfaces provided 
with relatively long hairs, in which the follicles and perifollicular tissues are 
involved in an exudative process, producing papules, pustules, tubercles, infil- 
trated patches, and crusts perforated by hairs. 

The title, sycosis, no longer indicates an idiopathic affection. It is 
employed in these pages to designate a group of different disorders, 
affecting, for the most part, the region of the male beard, which may 
be for practical purposes classified as follows : 

(A.) Coccogejsotjs Sycosis. — In this group are to be studied the 
most numerous of the cases to which the term sycosis non-parasitica 
was once given. They are all due to invasion of the pilo-sebaceous 
crypt with pus cocci. These pyogenic organisms may be either 
primarily or secondarily effective in producing the symptoms of the 
disease ; in the latter event they, in many cases, follow the disorders 
included in the group here last named. 

(B.) Bacillogenous Sycosis. — This is the disorder described by 
Tommasoli (Monatsch. f. prakt. Derm,, 1889, p. 483). 

(C.) Hyphogenous Sycosis. — This is a disorder due to the 
presence of the trichophyton (trychophytosis barbae). It is described 
in this work among the tineas, and is rarer than the other forms here 
tabulated. 

(E.) A group of Sycosiform disorders can also be recognized 
which differ somewhat from those named above. They include the 



THE COCCOGENOUS DERMATOSES. 227 

pseudo-sycoses, the eczemas limited to the region of the beard with 
acneiform features, the eczemas of the same region with seborrho'ic 
complications, and the still rarer sycoses due, as I believe, to tuber- 
culous infection of the pustular lesions of ordinary sycosis. 

The description which follows relates to the parasitic forms of 
sycosis not complicated by the presence of the trichophyton : 

Symptoms. — The lesions appear upon the face, involving one or both 
cheeks successively or simultaneously, the chin, upper lip, eyebrows, 
scalp, axilla?, and pubes. It is, however, almost always a disease 
limited to the region of the beard in men. In this respect it differs 
from acne and other disorders of the sebaceous glands of the face 
with which authors have sought to identify it, since not only is it as 
a rule strictly limited to the region of the beard, but the non-hairy 
portions of the face of the patient are free from comedones, acne 
lesions, and other symptoms of a cutaneous disorder. 

When seated upon the upper lip the first symptoms may be a nasal 
catarrh ; elsewhere an eczematous attack may precede the onset of 
the disease. It may be ushered in with such acute symptoms as are 
found in the early stage of some of the forms of eczema, tumefaction 
accompanied by a sensation of heat and burning ; but often a few 
isolated and indolent lesions whose presence scarcely awakens atten- 
tion, are the first traces of the disorder. Soon may be recognized a, 
larger or smaller number of discrete, flattened or conical, reddish and 
painful papules, tubercles, or pustules, whose anatomical seat is dis- 
tinguished as the pilary follicle by the penetration of each by a fila- 
ment of hair. These lesions may persist, and when typically discrete 
and visible at the part where the hair makes its exit from the duct of 
the follicle have suggested the appearance of the surface of the fig, 
whence the disease has its name. They are apt to occasion a burning 
and at times a decidedly pruritic sensation when, being picked or 
torn open by the fingers, the pus concretes into a crust at the base of 
the hair. In severer cases these lesions while not coalescing, are so 
closely set together as to form a patch of continuous infiltration. 
These patches may be weeping or crusted ; in the latter case the 
crusts are apt to be small and numerous, each being limited to the 
shaft of a single hair, and leaving when removed a minute erateri- 
form excavation at the mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and 
sooner or later, distinct patches of disease are thus formed. When 
fully developed, the surface of the skin is reddened, swollen, infil- 
trated, and thickened ; covered irregularly here and there with papules, 
pustules, crusts, scales, and often with excoriated surfaces. The dis- 
ease is apt to lapse into chronic conditions, usually as the result of 
improper treatment; and in ancient cases the deformity is character- 
istic and totally unlike that produced by the vegetable parasites. 
The hairs are usually fixed firmly in their follicles, but from those 
where active suppuration is in progress they may be plucked without 
occasioning much pain. In the cases which have been treated for 
years, the hairs are thin and decidedly lacking in vigor. 



228 DISEASES OF THE SKIN. 

In typical and neglected cases of long standing, where the region 
of the beard is involved, an important clinical feature is the symmet- 
rical, general, and uniform involvement of the entire surface. The 
picture of one cheek is very nearly that of the other. The thin 
hairs scarcely serve to disguise the reddened, tumid, painful surface 
beneath, displaying the several lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli- 
cate the process. . It is occasionally acute in its course, but more 
often chronic and rebellious. A typically chronic and untreated case 
of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs described above as a consequence of long 
persistence of the disease is far more characteristic of it than any 
distinctly resulting alopecia. The latter, however, very rarely occurs, 
but is then remediless. The same may be said of resulting cicatriza- 
tion, which is one of the very rarest of consequences, and generally 
due to bacillogenous infection. 

The absence of certain symptoms in this disorder is as significant 
as the presence of others. Adenopathy of the cervical glands is very 
rare, and when present should awaken suspicion of another malady. 
The disease when of longest persistence as to time, produces great 
unsightliness, but no deep-seated, subcutaneous, small- or large-nut 
sized nodules or tubercles, forming the "lumps" so characteristic of 
trichophytosis of the beard. It is a disease of chronic course, which 
may last for years and be characterized by relapses and aggravations, 
but is entirely curable, and it is only in neglected and badly treated 
cases that such persistence may be expected. 

Etiology. — The disease is unquestionably due to either primary or 
secondary invasion of the pilo-sebaceous follicle with micro-organisms. 
Obviously in many cases there is a special reason for the accessibility 
of these germs to the crypts where they are lodged. Shaving, and 
the use in common of towels, brushes, combs, etc., in public estab- 
lishments (club-houses, barber shops, hotels), and the employment 
of pillows, lounges, and reclining chairs in public resorts are often 
the origin of the mischief. 

It is encountered chiefly among men after puberty, and these in all 
social conditions and grades of health. It is not transmissible by 
heredity. The mere performance of shaving is not known to pro- 
duce it. At times, the immediate cause of the disease is recognized 
when the upper lip is constantly irritated by the discharge from a 
profuse nasal catarrh. In others again, all the causes of eczema may 
be invoked in explanation of the result. 

A careful study of many cases suggests that the hairs themselves 
are among the aggravating causes of the disease and the sources of 
its peculiar obstinacy. In health the motions of the free shaft of 
the hair do not irritate the follicle in which it is set. In conditions 
of disease it is quite different. Each free hair operates like a lever 
upon the inflamed ring of tissue which encircles it on its escape from 
the follicle beneath, and this whenever by the touch of the hand, by 
the action of brushing, by currents of air, or by any agency what- 



THE COCCOGENOUS DERMATOSES. 229 

ever, a movement is imparted to it. Every such movement teases 
to a variable degree the surface beneath, already irritated ; and when 
estimate is made of the hundreds of such movements to which each 
hair is subjected during a period of twenty-four hours, the relative 
importance of tin's apparently insignificant factor may be appreciated. 

Pathology. — The disease is due to pyogenic cocci exciting an 
inflammatory process, which, whether origiually follicular or peri- 
follicular in seat, may extend unquestionably either toward or 
from the follicle. Sometimes the extraction of the hair is followed 
by a drop of pure pus, which exudes from the follicle ; and the root- 
sheaths of the hair are seen to be altered in consequence of the cir- 
cumscribed follicular abscess. At other times, the follicle itself is 
free from disease, and the exudative process has evidently expended 
itself upon the peri-follicular or even the inter-follicular tissues, in 
which case the papillary layer of the derma exhibits the usual phe- 
nomena of hyperemia, infiltration, and multiplication of protoplasm, 
with abundant vascular dilatation. 

The micro-organisms recognized (by culture and reinfection) as the 
effective agents in the production of Tommasoli's bacillogenous syco- 
sis were bacilli with rounded extremities presenting an elliptical or 
ovoid appearance. They measured 1.0-1.5 x 0.25-0.3 mm. The 
symptoms clinically resembled those of coccogenous sycosis. 

According to Robinson, the disease always begins as a peri-follic- 
ular inflammation, under the influence of which transuded serum 
penetrates the follicle. Maceration and eventual destruction of the 
root-sheath of the hair result with the ultimate production of pus 
within and without the follicle. The pus, when the hair remains in 
the follicle, finds its way to the surface by breaking through the epi- 
dermis near the hair ; occasionally exit is obtained between the shaft 
and the follicle-sheath. 

Diagnosis. — The most important consideration here is the distinc- 
tion between the coccogenous and the hyphogenous forms of disease 
of the region of the beard, upon which naturally the microscope 
finally decides. Still the clinical features of the disease are quite dis- 
tinct. The coccogenous form is recognized (a) by the greater redness 
of the involved surface ; (b) by the extension of the disease in ad- 
vanced cases to larger areas of symmetrical involvement ; (c) by the 
more superficial character of the lesions, and (d) by the firm implan- 
tation of the hairs in their follicles in the earlier periods of the dis- 
ease, and their relative freedom in all cases from fracture and relics 
in the form of stumps. The hyphogenous disease of the hairs is 
peculiar, in consequence of (a) decidedly less redness of the surface 
attacked ; (6) its frequent limitation to a circumscribed area, or to 
several such, irregularly dispersed over a large region ; (c) the pecu- 
liar " lumpy, tubercular, nodular, and uneven " characters of the 
patch, upon which Duhring has laid significant emphasis ; and (d) 
the earlier loosening of the hairs in their follicles, as also of the 
occurrence of fractured hairs and stumps, exhibiting usually at the 
bulb unmistakable evidence of the nature of the disease. The malady 



230 DISEASES OF THE SKIN. 

is often mistaken for syphilis, chiefly on account of its deformity, but 
the pustular syphiloderm is very much less chronic in its course, is 
never limited for years to the face exclusively, and, when long per- 
sistent in one locality, is characterized by ulceration and the produc- 
tion of very characteristic crusts. 

Eczema may complicate the coccogenous disease by preceding or 
following it ; but typical instances of the two disorders may be 
recognized by the occurrence, in the former case, of a discharging 
disease not usually limited to the region of the beard, characterized 
by a more intense itching, and with marked absence of the papulo- 
tubercular lesions described above. 

The lesions, moreover, in eczema are not invariably perforated by 
hairs. Erythematous eczema of the shaven face is reddish in color, 
and desquamates, after full evolution of the disorder, without pustu- 
lation. 

Treatment. — In all cases of sycosis, the essential and important 
step is the continual removal of the hairs which, as indicated above, 
are the chief sources of aggravation of the disease. This is best 
accomplished by epilation or shaving, which, though often painful at 
the onset, are soon well tolerated by the sufferer. The majority of 
patients, however, object to the removal of the beard, far more on 
account of the consequent greater exposure to view of the deformity 
induced by the disease (then no longer partly masked by the hairs) 
than on account of the distress occasioned by the operation. To 
these objections there is but one response. The shaving is essential ; 
the deformity is rapidly reduced after its successful initiation ; the 
discomfort diminishes with each repetition of the process. For the 
disease in patients positively refusing to have the beard removed 
whose cases are so severe as to require it, the practitioner will do well 
to decline to be responsible. There is no limit to the tedious and 
obstinate course of the malady in the one case ; and in the other, the 
results are speedily satisfactory, often in the course of a few weeks. 

When there is much tenderness, pain, swelling, pustulation, or 
crusting, the hairs may first be clipped short, and a bland poultice 
of oil, elm-bark, or bread and milk applied. The practice in Vienna 
is to substitute for the latter strips of soft muslin or linen spread 
with diachylon ointment, firmly bandaged over the cheeks, chin, 
or lips for from twelve to twenty-four hours, after which the razor is 
passed over the entire surface. 

The integument which thus becomes visible, is usually a reddened 
infiltrated area, with pustules, papules, pustulo-papules, and some 
crusts dispersed here and there over it. This is best treated by hot 
water lotions, borated or alkaliuized, after exit is given to all puru- 
lent collections ; and then a bland ointment is to be applied at night, 
and a borated dusting powder in the morning. The subsequent 
treatment is largely that of eczema of equal grade of severity. In 
the more acute periods, the oleated lime-water, medicated with calo- 
mel or zinc oxide, half to one drachm (2.-4.) of either to the pint 
(512.) may often be employed with benefit; or for this may be sub- 



THE COCCOGENOUS DERMATOSES. 231 

stituted two ounces (64.) each of linseed oil, castile soap, and paraf- 
fin, to the pint (512.) of aqua calcis. Later the Lassar paste or 
ointments may be used, particularly cold cream, to which either sul- 
phur, the zinc oxide, or, less preferably, one of the mercurials may 
be added. Lotions of the mercuric bichloride, sulphur, alcohol, 
cologne water, or iodated glycerin, may be useful in stimulating any 
indolent patches of infiltration. The treatment of these is indeed 
that of chronic eczema. 

Epilation is often essential for relief of the disease ; and, by many, 
in chronic cases severer methods are employed, including the use of 
green soap, tar, and cauterization with acetic and even nitric acids. 
Erasion with the curette is to be named in the same category. These 
measures have been employed in aggravated cases ; but as the dis- 
ease is certainly curable in a majority of patients without having 
recourse to these heroic methods, they are to be regarded in the light 
of a dernier ressort. It is not necessary in the majority of cocco- 
genous forms of sycosis, either to epilate or employ caustics. By 
repeated and frequent use of hot borated water, and the milder 
stimulants, with constant shaving, the desired result is always within 
reach. Shaving should be continued for nearly one year after all 
traces of the disease have disappeared ; and it is a point of some 
importance to substitute a continuously applied borated powder for a 
fatty application, so soon as the skin will tolerate the persistent use 
of the former. 

Van Harlingen advises for acute cases a wash composed of half a 
pint (256.) of rose water, to which one drachm each (4.) of precipi- 
tated carbonate of zinc and oxide of zinc in powder have been added, 
with two drachms each (8.) of glycerin and dilute liquor plumbi 
subacetatis. Veiel recommends a solution of pyrogallol, one part to 
fifty, for painting over the part affected, followed in the day by 
emollient cataplasms, and in the night by diachylon or weak tannin 
ointments. Sycosis of other portions of the body is to be treated as 
described for the region of the beard. 

Internally, treatment when indicated, should be of the kind de- 
manded by the accidental condition of the patient. It is a matter 
worthy of special attention, however, to purge every previously 
treated case of all suspicion of an artificial element, by withdrawing 
for a proper time all internal medication. The disease is so disfigur- 
ing that many patients swallow the iodide of potassium, arsenic, and 
other deleterious drugs, for months before consulting one who is 
wiser than they in these matters. Exposure of the face to dust, 
smoke, wind, and other sources of irritation should be for a time 
avoided. 

In the hygienic management of these cases all use of tobacco and 
alcoholic beverages is to be abandoned. Even the drinking of hot 
tea, coffee, and stimulating beverages of other kinds is to be inter- 
dicted. The diet should be of the simple character recommended in 
eczema. Inasmuch as many patients suffer from a coincident nasal 
catarrh, I condemn the use of hot baths, and order for patients, 



232 DISEASES OF THE SKIN. 

able to endure the shock, daily cold sponging of the bodily surface 
followed by brisk friction with the flesh brush or coarse towels. 

In acute cases it may be desirable to begin treatment with a brisk 
mercurial cathartic, and the alkaline diuretics advised by authors 
will, at least, do no harm if judiciously employed. The same may 
be said of calx sulphurata and minute doses of calomel in the pus- 
tular stages of the affection. But in other cases cod-liver oil and 
iron are demanded by the general condition of the patient, usually 
one of the class exhibiting the evidences of " hospitalism." No 
firm believer in the coccogenous etiology of the disorder will, how- 
ever, expect by these measures alone to relieve the disease. 

Prognosis. — The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or be very greatly 
improved by judicious treatment. The latter requires the personal 
supervision of the physician and close attention to details. 

In exceptional cases the disorder is exceedingly chronic and obsti- 
nate, and requires perseverance on the part of both physician and 
patient to attain the desired end. Relapses are of frequent occur- 
rence, due usually to neglect of antisepsis after apparent recovery. 
In a few very rare cases (tuberculosis) there is cicatricial tissue left 
after repair. 

Dermatitis Papillaris Capillitii. 

Pian Ruboide, of Alibert. 

Under this title Kaposi describes a disorder characterized by pin- 
head sized, isolated or confluent elevations of the surface, with in- 
terspersed pustules, which finally form _cicatriform plaques over 
which the hairs are either clustered in tufts or totally absent. The 
pilary filaments are atrophied yet firmly fixed in their follicles, and 
suffer elongation or fracture before withdrawal. The disease is 
encountered chiefly upon the nucha, occiput, and vertex. Papil- 
lomatous vegetations, crust-covered, hemorrhagic, and with a foul- 
smelling secretion, sometimes form, and eventually retract into a 
sclerotic tissue. 

The author has seen and described typical cases of this disorder, 1 each 
of which concluded with the production of a keloid-like, cicatriform, 
irregularly shaped, but circumscribed elevation of the surface. This 
feature is that by which it specially differs from all other sycosiform 
disorders. The disease seems to be due fully as much to inflamma- 
tory processes in the subcutaneous tissue between the unyielding 
pericranium and the thick scalp as in the derma proper, and is not, 
therefore, strictly speaking, a dermatitis. Puncture, for example, of 
one of the pin-head sized pustules, commonly gives exit to the usual 
quantity of pus ; but pressure upon the scalp in the periphery will 
at once be followed by the appearance of a still larger quantity of 
similar pus, which evidently is expressed from a circumscribed sub- 

1 See a paper on this subject by the author, published in the Journal of Cutaneous and 
Venereal Diseases, vol. i., No. 2, p. 33. 



THE COCCOGENOUS DERMATOSES. 233 

cutaneous abscess. When by such pressure the abscess cavity is 
emptied, it slowly fills with venous blood, and produces a firm, 
semi-solid elevation of the surface, which subsequently undergoes 
sclerosis, and the starved hairs above behave in the manner well 
described by Kaposi. The papules and plaques are formed in a 
similar way, by the abundant supply of venous blood. The case of 
one of the author's patients (presented at the clinic) had been erro- 
neously diagnosticated by a surgeon as aneurismal in character. 
Puncture of all such semi-solid, cicatriform lesions is invariably 
followed by oozing of venous blood in abundance. The disease is 
chronic in character, particularly liable to relapse in crops of pilary 
or peripilary pustules and papules, and extends from nucha to vertex, 
curiously avoiding the frontal and temporal regions. Over the bald 
or partially bald keloid-like elevations there is seen, in some cases, a 
species of seborrhoea in the form of more or less adherent, fatty 
crusts, with occasional characteristic tufts of hairs. None of these 
hairs was invaded by a parasite, though repeatedly examined with 
the microscope with a view to such discovery. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 
the venous supply of the scalp is not only greatest, but in most 
direct connection with the large vessels beneath, and where an inflam- 
matory process in the derma or subcutaneous tissues invites with 
readiness a pathological afflux of blood. Such a focus, limited be- 
neath by the dense calvarium, aud with the relatively thick scalp 
above, readily undergoes organization and sclerosis, the subsequent 
behavior of the hairs and hair-follicles being an accident of the pro- 
cess. 

According to Besnier and Doyon, the disorder is only a papil- 
lomatous development, likely to occur in this region of the scalp 
as a sequel of epilating, cicatricial (keloid) acne, eczema, or trauma- 
tism. 

Sangster (in a paper read before the International Medical Con- 
gress in London, 1881) described a pigeon's-egg-sized tumor of the 
scalp, which Kaposi, who was present, recognized as a case of der- 
matitis papillaris capillitii. 

The method of treatment to be employed in this rare disease can 
scarcely be described as established. The affected surfaces are first 
freed from the subcutaneous abscesses by puncture and expression of 
the contents. Then the patch is washed with hot carbolized water, 
dusted with boric acid or iodoform, and a compress, moistened with 
an antiseptic solution, such as corrosive sublimate wash, rather firmly 
bandaged over the part. When the pathological fluids no longer 
form under the scalp, the patch is best epilated, and anointed with 
a salve containing one drachm (4.) of precipitated sulphur to the 
ounce (32.) of scented vaseline, which may also be kept constantly 
over the part. When crusts form, they may be removed by sham- 
pooing with green soap. 

Generally, internal treatment is suggested by the constitutional 



231 DISEASES OF THE SKIN. 

condition of the patient, and this should often include cod-liver oil, 
the ferruginous tonics, and a roborant regimen. 

(G.) Impetigo. 

Lat., impetere, to rush upon. 

Impetigo is an acute inflammatory affection of the skin, in which discrete, 
roundish, and acuminate or globoid vesicles, of the average size of a coffee- 
bean, form and rapidly fill with pus, which, being set free after rupture of the 
lesions, desiccates in characteristic crusts. 

The interesting researches of Bockhart and others have demon- 
strated that the symptoms once designated by the term impetigo, as 
also those of furunculosis and sycosis, are purely and simply the 
local results of infection with the staphylococcus pyogenes aureus 
and albus. The symptoms to which in different cases these several 
names are given, differ in consequence of the accidents of location, 
the sex of the patient, and the opportunities for extension of the dis- 
ease. 

Hebra stated, even in his day, that the pustular, cutaneous affec- 
tion described by authors under the name, Impetigo, had no existence 
as an independent disease. Unquestionably a long list of disorders 
hitherto described under this term have been, in fact, forms of pus- 
tular eczema. The reasons for retaining the name given above and 
for assigning to it certain peculiar eruptive features, are based upon 
the simple fact that the latter, probably in consequence of the opera- 
tion in a similar way of similar causes, reproduce themselves again 
and again, so as to exhibit the same clinical picture in different 
patients. The convenience of the name impetigo, as descriptive of a 
group of cutaneous symptoms, is, therefore, the sole reason for its 
retention. 

Symptoms. — The disease is sufficiently common in practice, being 
observed chiefly in children and young adults of both sexes. In 
such patients, one to twenty or more isolated and often widely 
separated minute vesicles or vesico-pustules usually acuminate, ap- 
pear upon the surface either simultaneously or in rapid succession 
occasionally after a slight access of fever. They are speedily trans- 
formed into split-pea sized or larger pustules, so rapidly, in fact, that 
often the early vesicular phase is not manifest, the lesions showing 
as minute pustules from the first. When fully developed, they are 
globular, yellowish-white in color, discrete, well distended with their 
puriform, rarely bloody contents, and projected clearly from the 
surface on which they rest. They may be surrounded by an erythem- 
atous areola, or be simply superimposed upon an integument of un- 
altered color. They may persist as such, or burst and their contents 
dry into a yellowish crust resembling honey, or into brownish-tinted 
concretions which adhere with firmness to the superficial and circum- 
scribed base, where a slight weeping can be determined. They are 
much more commonly observed upon the face, but are recognized 



THE COCCOGENOUS DERMATOSES. 235 

elsewhere, always sparsely upon the trunk and extremities. The 
eruption is never in any sense generalized, its characteristic feature 
being the few T ness of the lesions, which rarely exceed twenty in num- 
ber, which are scarcely ever grouped, and which occur in capriciously 
selected locations. The subjective sensations are slight, and the erup- 
tion is more picked than scratched. It is common in dispensary and 
hospital patients ; and since these are often the victims of neglect and 
the subjects of vices of nutrition, it has been considered the appanage 
of scrofula. But the disease is also encountered in well-nourished 
and rosy-cheeked children. In the latter, when well cared for, the 
eruption proceeds regularly to its natural resolution, while, in the 
former, it is prolonged aud often aggravated, thus attracting to a 
greater degree the attention of the physician. The pustules are 
never umbilicated, never seated upon ulcers, and never followed by 
cicatrices. 

Etiology. — The cause of the disease is simply infection w T ith pus 
eocci. It occurs rather at the age of childhood than in infancy and 
adult life, a period when the hands are first brought into habitual 
contact with the face ; and these are, quite suggestively, the two sites 
of election. The lesions are very rarely scratched, more often torn 
with the nails in picking, so that the crusts may be a little blood- 
colored. There is reason to believe that the habit of picking the 
nose and other parts of the face and body with unwashed hands, is 
the chief source of the mischief. In later life the habit of refraining 
from carrying the hands to the face when the former are soiled, 
becomes instinctive. Before this instinct is well established, that is 
in childhood, the hands will convey to the head any particle of filth 
or dust with which they may have been brought into contact. 

Pathology. — The lesions have been examined microscopically by 
Bockhart and others, who have thus been able to establish clearly 
the coccogenous origin of the disorder. Plainly, each is but a dis- 
tinctly circumscribed and superficial pea- to bean- sized abscess, the 
result of infection with the staphylococcus pyogenes aureus and albus. 

Diagnosis. — In order to establish the identity of this affection, it 
is necessary to define its exact differences from eczema pustulosum. 
These are, first, the absence of infiltration of the tissues affected ; 
second, the absence of itching ; third, the failure of the lesions to 
form patches ; fourth, the isolation and wide separation, each from 
the other, of lesions distinctly pustular ; fifth, the large development 
and rather persistent character of individual pustules ; aud, sixth, 
after involution of the latter, the evident termination of the disease, 
which does not, as does eczema in many cases, progress to form a 
freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct morbid process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema 
which is often originated by less irritating causes. 

In ecthyma, the pustules are much more formidable in appearance, 
in consequence of their size, depth, inflammatory base, areola, flat, 
hard, bulky crust, and erosive action upon the skin. 



236 DISEASES OF THE SKIN. 

From impetigo contagiosa, the disease is distinguished chiefly by 
the absence of the evidences of contagion. The lesions of the latter 
are also, at first, strictly vesicular, not vesiculo pustular or pustular, 
there is often umbilication, and the pus is auto-inoculable. The 
lesions may also coalesce. 

Treatment. — The individual pustules are to be opened with a 
comedo-needle ; the purulent contents gently removed by washing 
with borated water, and the floor smeared with any mild ointment, 
such as five grains to a half scruple (0.33-0.66) of ammoniated mer- 
cury to the ounce (32.) of cold cream, or the subnitrate of bismuth 
half a drachm (2.) to the ounce (32.), or the benzoated zinc salve. 

Van Harlingen recommends, after the application of a salve on bits 
of muslin, the covering of the whole with waxed paper. A dusting 
powder containing calomel may be substituted for the salve or em- 
ployed afterward. The disease tends to spontaneous recovery, if the 
lesions are not irritated. When they are situated within reach of a 
child's tongue, which is constantly thrust out of the mouth to moisten 
them, they may linger obstinately, and require protection by flexile 
collodion. 

(H.) Impetigo Contagiosa. 

(Porrigo Larvalis, Porrigo Contagiosa, Pemphigus Acutus 
Contagiosus Adultorum [Po^toppidan].) 

Impetigo Contagiosa is an acute, inflammatory, contagious disease, characterized 
by the formation of multiple, usually isolated, flattened or slightly umbilicated, 
roundish or ovalish, split-pea-sized and larger, vesicles, vesico-pustules, or blebs, 
which terminate by the production of yellowish, slightly adherent crusts. 

In 1862, Dr. Tilbury Fox observed and described the disease now 
under consideration, to which he gave the name by which it is most 
generally recognized to-day. 

Symptoms. — The eruption, occurring in infancy, childhood, and 
early adult life, is often preceded by a febrile process, and appears in 
the form of rarely numerous, isolated vesicles, vesico-pustules, pus- 
tules, or bullae, usually about the face, but also on the neck, buttocks, 
hands, or feet. In severe cases these are surrounded by an areola. 
The lesions are roundish, flat, have the average size of a split-pea, 
and become covered in the course of a few days with dry, granular, 
straw-colored crusts, which adhere closely to the slightly reddened 
base on which they rest. Very superficial erosions are to be discov- 
ered beneath, which become rapidly covered with epidermis. They 
occasionally coalesce, and their complete involution requires from a 
week to a fortnight. When of the dimensions of bullae, a pseudo- 
umbilication may be observed at the apex, produced solely by flac- 
cidity of the roof-wall, which is never tied down, as in variola. The 
contents of the lesions are inoculable and auto-inoculable, the disease 
thus spreading from one member of a family to another, and also 
from one part of the body of an individual to another. The mucous 
surfaces are said to be occasionally invaded. The subjective sensa- 



THE COCCOGENOUS DERMATOSES. 237 

tions are mild, the itching being rarefy severe. The disease rims a 
tolerably definite course, being usually at an end in a fortnight. It 
may recur. Kaposi states that it is at all times accompanied by 
submaxillary adeuopathy. 

The latest studies of this subject indicate with clearness that im- 
petigo contagiosa is to share the fate of impetigo simplex, sycosis, 
and furunculosis in the loss of its identity as a disease. The several 
names are here retained as convenient cliuical designations of symp- 
tom-groups whose career differs in consequence of the age of the 
subjects of the disorder, their habits, environment, and opportunities 
for contagiou. 

Impetigo contagiosa is practically a term indicative of the symp- 
toms of several widely differing causes, all practically resulting in a 
coccogenous or hyphogenous disorder. In some cases the irritation 
is set up by the encroachments of the trichophyton. In others, there 
are pediculi of the occipital region, and the scratching set up in 
children in consequence of their attacks furnishes the opportunity 
for infection with the staphylococci. In yet other cases, the micro- 
organisms responsible for varicella have unquestionably operated to 
produce the symptoms. 

It is to be remembered that the several clinical pictures differ on 
account of the greater or less diffusion of the contagious elements in 
each case ; for example, there may be a few isolated pea-sized and 
larger vesico-pustules on a single hand ; or many clustered about the 
mouth and lips ; or dense greenish crusts succeeding such lesions 
over occiput or scalp ; or much larger pustulo-bullous elements over 
the legs, torn, scratched, and thickly crusted, or even covered with 
hsemorrhagic incrustations. The disorder is not often seen in private 
practice ; but in public patients among the cachectic, the filthy, and 
the neglected. 

Etiology and Pathology. — Kaposi, Piffard, and Geber, all describe 
a microscopic fungus which they discovered in the crusts of the dis- 
ease, but neither they nor Tilbury Fox were able to demonstrate the 
existence of a parasite in the contents of the lesions. Plainly, a 
parasitic vegetation on the exterior crust can have no etiological sig- 
nificance in this connection. The eruption often occurs during con- 
valescence from a more or less actively contagious disease. The 
antecedence of some fever in many cases is admitted by all observers. 
Duhring and Fox himself have seen it follow vaccinia ; and the 
former admits that some connection between the two seems probable. 
The author has seen it occur typically in a series of children, each of 
whom was convalescent from varicella ; and in one interesting case, 
that of a young woman convalescent from confluent variola, the lesions 
sprang from an integument where the pigmentation of the scars of 
the last-named disease had not begun to disappear. 

Stel wagon, in 1883, 1 making a new study of the subject, reports 
only six cases out of eighty-eight observed by him following vacci- 

1 Med. Record, Dec. 22, 1S83. 



238 DISEASES OF THE SKIN. 

nation, and concludes that the disease is non-parasitic, but an acute 
specific contagious exanthern, with cutaneous lesions pursuing a 
definite career. 

Pontoppidan, in 1885, found, as had many before that date, only 
epithelial cells, blood-corpuscles, and detritus in the crusts, never 
any indications of a parasite capable of explaining the etiology of 
the disease. 

Dewevre 1 reports a number of successful inoculations and auto- 
inoculations practised with the contents of the vesico-pustule, with 
finely powdered impetiginous crusts and with the products of scrap- 
ing the subjacent erosion. He reports finding reticulated mycelial 
tubes of the thickness of three thousandths of a millimetre in the 
rete mucosum beneath the lesion. 

In 1884 the author succeeded in producing an almost typical 
vesico-pustule upon his left forearm by inoculation, all due precau- 
tions observed, with the moistened debris of crusts. This was done 
in the Dermatological Clinic, the crusts being taken from typical 
lesions upon the face of a young girl inoculated while under obser- 
vation from the lesions of exactly similar character on the face of 
her twin sister. The lesion on the forearm produced a characteristic 
crust, which in seven days was also used for the inoculation of two 
students then present at the Clinic, in one of whom there was no 
result, and in the other an abortive lesion. 

The disease is contagious, and its lesions inoculable and auto- 
inoculable, whether as a coccogenous or hyphogenous process. 

Diagnosis. — Impetigo contagiosa is distinguished from impetigo 
simplex by its frequent pyrexic symptoms ; its flat, yellowish, super- 
ficial, friable crusts ; its vesiculo-bullous rather than distinctly pus- 
tular lesions ; and its contagiousness. In pustular eczema there are 
itching, infiltration, profuseness of discharge, indefiniteness of dura- 
tion, coalescence of lesions, and extensive bulkier crusts. In varicella, 
the lesions are small, much more widely distributed over the body, 
and are vesicular only, rarely bullous. In pemphigus and herpes 
iris, the seat, character, and period of evolution of the lesions will 
suffice to establish the diagnosis. 

Treatment. — The crusts are removed and a salve applied consisting 
of cold cream or vaseline with from five to ten grains to the ounce 
(0.33-0.66 to 32.) of ammoniated mercury. 

(I.) Ecthyma. 

Gr , fudv/ua, a pustule ; etcdvu, I burn out. 
Ecthyma is an inflammatory disease of the skin characterized by the formation 
of few or many, large, discrete pustules, implanted upon a dense, deeply situa- 
ted base, the pus of which dries into dark colored, firm, bulky, and attached 
crusts, beneath which there may be superficial ulceration and resulting scarring. 

The term ecthyma, like several of the titles of chapters imme- 
diately preceding, no longer points to a distinct disease. It repre- 

i Arch, de Med. et de Pharm. Mil., Sept. 16, 1885. 



THE COCCOGENOUS DERMATOSES. 239 

sents rather a tolerably definite group of symptoms readily separable 
clinically from other affections produced by different causes. The 
most common is infection of the skin of the lower extremities with 
pus cocci after scratching ; then follow the traumatisms primary and 
secondary associated with pediculi of the body (pediculus vesti- 
menti) ; and combinations of these with bed-bug bites ; general 
filthiness of the person and clothing of body and bed ; and the 
cachexia of most patieuts in these conditions. The term ecthyma is, 
however, not to be discarded, as it suggests to the mind not merely 
these composite etiological factors, but the characteristic picture pro- 
duced as a result in the skin. 

The disease is characterized by the occurrence of one or several, 
roundish, bean- to filbert-sized, yellowish or reddish pustules, which 
are the result of a distinctly circumscribed, inflammatory process, 
limited to the base of each lesion, or extending from it at the peri- 
phery in a diminishing hyperemia. This process is distinguished 
by the formation of an indurated phlegmon at the base of the pus- 
tule, which is converted into a loss of tissue involving the corium. 
The purulent or sanguinolent contents of the lesions dry in dark 
colored, thick, rough, adherent crusts, the color being somewhat 
dependent upon the quantity of the blood with which they are com- 
mingled. On the removal of this concretion, a minute, shallow, and 
circular pit is discovered, invading the true skin to various depths, 
and lined with a tenacious, puriform, and often blood-stained product. 
When carefully wiped clean, this solution of continuity, which really 
constitutes a minute ulcer, is seen to have a floor reddish or grayish 
in color, and indolently granulating. 

The pustules may be acutely or indolently developed, and be, 
when multiple, coincident or successive. They occasion rather a 
sensation of heat, burning, and pain, than of itching, the latter being 
usually more distinct when the lesions are healing under their crusts. 
Their formation may be preceded by mild general pyrexia. They 
occur at all ages and in both sexes, usually upon the extremities, but 
also upon every portion of the body. 

Etiology. — The pyogenic cocci are the efficient causes of most 
lesions ; practically the agents capable of producing eczema and der- 
matitis (traumatism, heat, scratching, parasites, etc.) operate in ex- 
cess, or in subjects affected with other diseases, such as anaemia, 
asthenia, struma, variola-convalescence, and menstrual disorders. 
Filth and neglect are most common aggravations ; in other words, 
that circumscribed cutaneous ulcer will be the angrier and the deeper, 
which occurs in the victim of any depressing disease, whose skin is 
scratched with nails begrimed with dirt, and is covered with the 
effete products of the excretory processes. The pus thus produced is 
in various degrees inoculable and auto-inoculable, as is the product 
of many inflammatory processes of similar grade. 

Pathology. — The pustule of ecthyma differs in no respect patho- 
logically from the pustule of eczema or the pustule of impetigo, 
save in the severity of the exudative process by which it is produced, 



240 DISEASES OF THE SKIN. 

and in its limitation to the exact site of external irritation. By the 
extension of that process to the coriurn, there is an actual loss of some 
of the elements constituting the papillary layer ; and the result is a 
cicatrix, which contracts as it grows older, and is, in milder cases, 
finally barely visible as a minute cicatriform punctum. One who 
frequently examines the skin of the entire body with care can usually 
detect the ancient sites of these lesions by their indelible though 
insignificant relics. 

.Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction between 
them is largely artificial, and based upon the severity of the inflam- 
matory process, there is small danger in the consequence. Kaposi 
well expresses the truth in his suggestion that there can be but little 
objection to the employment of the term, ecthyma, when it is desired 
to characterize precisely the pustular grade of any cutaneous inflam- 
mation at a given time. The pustules of variola are " ecthyma- form/' 
and many of those seen in syphilis possess similar characters. But 
in each the history of the general affection should throw light upon 
the identity of the cutaneous disease. In the latter, moreover, the 
ulceration at the base of the lesion exhibits the pronounced features 
of the syphilitic ulcer in its secretion, floor, edges, base, crust, and 
career. 

The crust, in particular, of the flat pustular syphiloderm has 
the rupioid conical appearance which suggests the shell of the oyster, 
and its underlying ulcer is larger and deeper than in ecthyma. In 
the furuncle there is usually a central core ; in impetigo, the pustules 
are not deep-seated, and there is no ulceration at the base. In im- 
petigo contagiosa the crust is superficial, yellowish, firmly adherent, 
and the lesions are more numerous. 

Treatment. — The general treatment of patients affected with ec- 
thyma is a matter of some importance. A proper regulation of the 
food and hygienic surroundings is not to be neglected. Tonics are 
frequently indispensable, including iron, quinine, and strychnia. 
The destruction of any pediculi and the cleansing of the skin by soap 
and water will often be sufficient to effect a great change. This is 
well illustrated in hospital practice, where the little patients rapidly 
improve after a bath, followed by inunction with vaseline, and a few 
substantial meals of a nutritious character. When the lesions are 
abundant, the treatment is in general that of pustular eczema. 
Crusts are to be removed after soakings with oil or fat ; and the 
floors of the former pustules, after washing with carbolated water, 
should be dressed with an ointment containing ten to fifteen grains 
(0.666-1.) of the ammonio-chloride of mercury to the ounce (32.) of 
lard. If the minute basal ulcers are sluggish, they may be. after 
careful cleansing, touched with a small swab dipped in a solution of 
the bichloride of mercury in the tincture of benzoin, one grain 
(0.066) to the ounce (32.) Carbolic or boric acid or iodoform 
may be employed for the same purpose. For the salve mentioned 
above, may be substituted one containing ten grains (0.66) of calomel, 



HERPES. 241 

or half a drachm (2.) of the subnitrate of bismuth to the ounce of 
salve basis. 

In every case of the disease it is desirable to inquire whether any 
medicines have been ingested prior to the appearance of the eruption, 
since these may be responsible for the lesions. 

The prognosis is always favorable. 



Herpes. 

Gr., epiTstv, to creep. 

Statistical frequency in America, 1.66. 

Herpes is an affection of the skin characterized by the occurrence of one or 
more vesicles filled with a clear serum, disposed in groups, usually seated upon 
an inflammatory base, limited to a certain region of the body, and pursuing a 
definite career within a relatively brief period of time. 

The term, herpes, is unquestionably responsible for a great deal of 
the confusion which has existed with respect to cutaneous disease. 
By the ancients it was employed, as its etymology suggests, to desig- 
nate a disease creeping or extending gradually over the surface or 
within the substance of the skin. By several more modern authors 
the term has been employed in a generic sense in a futile attempt to 
distinguish a series of so-called u herpetic diseases/ 7 and even her- 
petic diatheses from those of a different complexion. 

The significance which attaches to the word in the minds of the 
dermatological authors of this day, is exceedingly simple, and is 
limited to the features conveyed in the definition given above. It 
will be seen that the description thus embodied is largely that 
of herpes zoster, an affection which is in this work considered 
separately. 

Symptoms. — The disease is declared by the occurrence of millet- 
seed to coffee-bean sized vesicles, single or relatively few in number, 
and in the latter case grouped, occurring as epiphenomena of a 
general febrile process, or as symptoms of an idiopathic disease. 
The lesions are usually short-lived, surviving but for a few days, 
and are filled with a clear, serous fluid which may become lactescent. 
After accidental or spontaneous rupture there is left a slightly 
tumid, superficial excoriation, which at times is characterized by a 
circumscribed hyperemia, slight infiltration, or oedema of the base 
and periphery. The subjective sensations are not usually severe, 
varying between moderate pain, itching, and heat. There are occa- 
sionally precedent chill and pyrexia; but no persistent lesion-relics 
result from complete involution. 

Heepes Facialis, Herpes Febrilis, " Cold Sores." — About 
the lips, mouth, cheeks, and alee of the nose, more rarely upon other 
portions of the face, lesions occur singly or in a group, possessing 

16 



242 DISEASES OF THE SKIN. 

the characters described above. Their occurrence is usually sudden. 
Their frequency about the lips has suggested the title, Herpes 
Labi a lis, under which they are described by several authors. The 
tongue, buccal membrane, palate, and larynx may participate in the 
morbid process ; and the lesions in such moist situations are repre- 
sented by isolated or grouped, dark-grayish patches of epithelium 
which are sensitive, and exfoliate. The functions of the mouth in 
articulation and mastication are thus rendered painful. The disease 
is common in acute pneumonia, and in malarial and enteric fevers. In 
these cases, as Kaposi has shown, the occurrence of the eruption by 
no means augurs favorably in every instance, as a fatal result may 
nevertheless follow. 

Often the lesions coalesce, forming a pea-sized bleb in an irregular 
line of elevated epidermis, spreading along the vermilion border of 
the lip and distended with a clear serum. The burning and itching 
sensations which accompany the lesions are often marked and dis- 
tressing. In the course of two or three days thin crusts form, whose 
exfoliation terminates the disorder. 

The connection between labial herpes and rigors has long been 
recognized, though particular attention has been directed to this 
relation by Hutchinson and Symonds. Beside the trophic disturb- 
ances of this nature, traumatism, exposure to solar heat, unusual 
fatigue, a simple coryza, exposure to a cold draught of air, and tem- 
porary gastric disturbances may suffice to induce the disease. There 
are patients who can produce the lesions at will by tickling the lips 
with a feather. There is in some individuals an unquestionable 
susceptibility to the disease. The disorder is always short-lived 
though often recurrent ; and the superficial crusts which terminate 
the process are never followed by scars. Symmers, of Aberdeen, 
has successfully cultivated a rod- or thread-shaped micro-organism, 
solid, filamentous, and without septa, obtained from the lymph in 
vesicles of herpes labialis. 

Herpes Progenitalis. — This disorder, also termed Herpes Prse- 
putialis, is characterized by the appearance of one or a group of 
transitory vesicles on the inner face of the prepuce, especially upon 
its upper limb, on the glans, the balauo-prseputial sulcus, and the 
adjacent integument ; in women, on the hood of the clitoris, the labia 
minora, the inner face of the labia majora, and adjacent surfaces 
even as far removed as the buttocks. 

There is usually precedent pruritus or a sensation of heat, followed 
by the appearance of one or several pin -head sized vesicles seated 
upon a tumid and hypersemic base. Within the preputial sac the 
lesions may either rupture at an early moment or assume the features 
described as presented upon the mucous membrane of the mouth. 
The resulting oedema of the prepuce is often displayed in an annular 
tumefaction encircling the glans, while the labia minora perceptibly 
project from the general vulvar plane. In these localities the floors 
of ruptured vesicles are particularly liable to be irritated (coitus, 






HERPES. • 243 



caustic, etc.), and then pus and even blood may be exuded with 
much angrier excoriation and resulting crusts of darker shade. In 
the course of a few days even these crusts fall, and the disease is at 
an end. Recurrence is common. 

Earely a first attack of herpes in the male results in an extraordi- 
nary sensitiveness of the balano-prseputial membrane, which persists 
for more than a year. The patients are usually middle-aged men, 
married, and virgin as to venereal antecedents. The membrane is 
then tumid, tense, slightly glazed, and dark red to dark purple in 
hue. Upon any undue sliding of the prepuce over the glans, a very 
superficial fissure occurs, whence a drop of serum oozes. The mem- 
brane becomes so sensitive that the passage of the finger over it is 
resented as though the conjunctiva had been touched. Unusual 
friction by the clothing or the use of a stimulating lotion is followed 
by intense pain and aggravation of symptoms, and the price of 
coitus is a week's rest in bed. 

Naturally the diagnosis of herpes progenitalis is between chancroid 
and chancre. The latter will be manifested by its induration, its 
period of incubation, and its characteristic inguinal adenopathy. The 
chancroid, whether in pustular form or inoculated abrasion, is ab 
origine ulcerative in tendency, capable of auto-inoculation, and often 
accompanied by sympathetic, inflammatory, or virulent bubo of one 
side. Balanitis, with its puriform secretion and superficial patches 
of reddened epithelium, is readily distinguished by its symptoms, 
though the two disorders frequently coexist. 

The practitioner should never forget that the patient who exhibits 
a herpes of the genital region to-day, may have been inoculated at 
the site of the lesions which may to-morrow or later take on the 
chancrous modification. The rule to be followed, then, is very 
simple. No individual with a progenital herpes can be assured of 
immunity against syphilis, till the longest period of incubation of 
the syphilitic chancre has elapsed since the date of last suspected ex- 
posure. 

Herpes progenitalis is almost universally the result of naturally 
or unnaturally induced sexual erethism. Its occurrence in an indi- 
vidual virgin as to such antecedents, may be due to the causes efficient 
in the production of herpes facialis. Unna, 1 in an interesting paper 
on the subject, has conclusively shown that, though relatively rare 
in chaste women, it is of common occurrence in prostitutes. 

Messrs. Diday and Doyon, 2 who have given special attention to 
the subject, believe that true herpes of the genital region is always 
of the recurrent type, and well marked by its special course, career, 
and consequences. All others of a false type are divided by them 
into [1] an irritative form, seen in women as the result of vagiual 
discharges, sexual irritation, etc ; [2] a pseudo-membranous or diph- 
theroid form, also occurring for the most part in women, vesicular 

1 Journ. of Cutan. and Ven. Dis., Aug., 1883. 

2 Les Herpes Genitaux, Paris, 1886. 



244 DISEASES OF THE SKIN. 

and even bullous in its lesions, whose rupture is the signal for the 
pseudo-membranous transformation ; [3] a neuralgic form, which is 
merely zoster of the genital region. 

Treatment. — The milder forms of herpes occurring about the lips 
and genitalia require the simplest treatment. Sponging with pure 
water, as hot as can be comfortably tolerated, is best followed by 
local use of a weak lead lotion, rose ointment, or zinc salve. About 
the lips it is well to protect the lesions with flexible collodion or isin- 
glass plaster. Occurring upon the genital region, the lesions are to 
be protected by the interposition of a pledget of lint or a borated or 
salicylated dusting powder. As a rule, ointments are unsuited for 
the moist mucous surface of the genitals, the odorous emanations 
from most diseases of such parts being retained disagreeably by all 
grease-containing compounds. Lotions answer a far better purpose, 
and these may be made stimulant with alcohol; astringent with 
tannin, the sulphate of zinc, or the sulphate of copper ; painless with 
opium or cocaine ; and antiseptic with carbolic acid or corrosive sub- 
limate. Prophylaxis by the local use of aromatic wine, or tannin 
and brandy, with continence, is a matter of importance. 

Herpes Iris. 

The behavior of the lesions in herpes iris differs somewhat from 
that just described ; and this has led several authors to consider the 
affection as a separate and distinct disease. As there is, however, 
some doubt respecting the question whether herpes iris should not be 
relegated to the dominion of erythema multiforme, it is assigned a 
provisional position in this connection and also considered in the 
chapter devoted to erythema. 

The symptoms at the onset are the occurrence of one or several 
vesicles or vesico-papules, which pursue their usual rapid career in 
two or three days. Upon th ehypersemic ring which surrounds these, 
a second and even a third and fourth circlet of similar lesions form, 
each pushing the areola further to the periphery of the patch. The 
older are in full retrogression while the newer are in the process of 
evolution ; and the red blush which surrounds the earlier is under- 
going color-changes from vivid to paler hues, while the zone of the 
latest vesicles is assuming its intensest shade. The lesions are pin- 
head to pea-sized, rather persistent and firm ; and terminate more 
often by resolution than by rupture and crusting. The concentric 
and parti-colored rings may make up a single patch an inch or more 
in diameter, or several such patches may form upon the surface of the 
integument. In the latter case the central disk of some of the patches 
will be seen to be made of confluent lesions. The eruption is most 
commonly situated upon the extremities, especially over the dorsum 
of the hands and feet, in which situation, especially when symmetri- 
cally developed, it is always, according to Kaposi, more nearly allied 
to erythema multiforme. It is, however, also rarely seen upon the 
face. The subjective sensations produced are usually trifling. Atyp- 



HERPES. 245 

ical forms occur where the lesions are imperfectly developed from 
papules, and also where, in consequence of an unusual exudation of 
serum, bullae appear. 

The points in which herpes iris most resembles erythema multi- 
forme are : the variegation of the tints in the peripheral integument 
(whence the name, iris); its localization upon the extremities chiefly ; 
its occasional symmetry ; its frequency in young adults ; and its 
tendency to occur in the spring and autumn. Per contra, herpes 
iris differs from other forms of herpes : in the absence of a precedent 
febrile state or neuralgic pain ; in its avoidance of regions near the 
mucous outlets of the body (preputial orifice, vagina, mouth) ; and 
in the behavior of the vesicular lesions after attaining their full 
development. 

The affection is evidently one upon the border-line between herpes 
and erythema multiforme ; and might be properly considered under 
either title. Its existence is another evidence of the impossibility of 
drawing hard and fast lines between all the clinical symptoms pre- 
sented by different diseases. 

It can scarcely be mistaken for other affections, in consequence of 
the elegance with which its lesions are disposed. Pemphigus simplex 
and pemphigus foliaceus differ decidedly in their career, however 
much they may, at the outset of exceptional cases, present certain 
points of resemblance. 

The affection tends to spontaneous recovery, and requires no treat- 
ment. A dusting powder may be applied over the surface, if need 
be, to protect the lesions from accidental rupture. 

Herpes Gestatioxis, or Pemphigus Hystericus, is a name which 
has been employed to designate erythematous, papular, vesicular, and 
bullous lesions, accompanied by marked pruritic and burning sensa- 
tions, occurring usually upon the extremities, but also upon other 
parts of the body. The subjects are usually pregnant or hysterical 
women, who are said to exhibit recurrent attacks in successive condi- 
tions of pregnancy or neurotic disorders. Personal experience has 
led the author to accept fully the view of Duhring, that this disorder 
should be included under Dermatitis Herpetiformis. 



24:6 DISEASES OF THE SKIN. 

Herpes Zoster. 

Gr., ^cJGTfjpj a girdle. Shingles, Lat., cingultim, a girdle. 

(Shingles, Zona, Zoster, Ignes Sacer, Hemizona. Ger., Feuergiirtel.) 

Statistical frequency in America: 1.15. 

Herpes Zoster is an acute exudative affection of definite career, characterized by 
the occurrence of groups of firm and distended vesicles, preceded, accompanied, 
or succeeded by neuralgic sensations, usually monolateral in distribution, and 
followed in some cases by persistent cicatrices, the cutaneous symptoms being 
always limited to an area of the skin supplied by a twig of one or more of the 
cranial or spinal nerves. 

Symptoms. — The eruption in this affection is usually preceded, 
for a period lasting from a few hours to days and even weeks, by- 
malaise or neuralgic sensations of moderate or severe intensity. 
These sensations are usually limited to the area of the integument 
subsequently or coincidently displaying cutaneous lesions ; but there 
are exceptions to this rule, as the pains are at times experienced 
elsewhere. Often, though limited to the region about to be attacked, 
they occur where pain is experienced in other neuralgias, at the points 
indicated by Romberg as corresponding to regions where cutaneous 
branches are given off by the nerve trunks. 

According to Fabre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease. 
This appears in the form of vivid and brilliant-red erythematous 
macules, groups of which, from six to ten in number, appear in the 
tract supplied by the affected nerve. The vesicles (which are gener- 
ally regarded as more characteristic of the disease) appear afterward 
in from a few hours to a day or more, spring from the macules, 
and are accompanied by a sensation of heat. These typically perfect, 
isolated vesicles vary in size, from a rape-seed to a coffee-bean. They 
appear in groups corresponding to the groups of the macules, from 
eight to a dozen in a single cluster, and appear successively, the indi- 
vidual members of each attaining maturity simultaneously in about 
one week, while the succession of others may prolong the period of 
efflorescence to an entire month. 

The lesions, when fully developed, exchange their early limpid 
contents for those of a lactescent or puriform character. They pro- 
ject well from the widely hypersemic base from which they spring ; 
are tense from complete distention ; and have no tendency to spon- 
taneous rupture, so firm is their roof-wall. When abundant, they 
may coalesce. Involution is accomplished by desiccation and the 
formation of yellowish-brown crusts, whose fall is succeeded in cer- 
tain cases by indelible scars. 

Several variations from the type thus described require notice. 
The vesicles may be few and typical ; numerous, abortive, and 
transitory ; or differ in type as they may be transformed into verit- 
able pustules or bullae, or become filled with blood from capillary 




HERPES ZOSTER. 247 

haemorrhage. In the latter event there is still further departure from 
the type in their tendency to spontaneous rupture aud subsequent 
ulceration. According to Kaposi, it is in such cases only that cica- 
trices form ; but this statement, in view of many clinical observa- 
tions, must be accepted with reserve. 

In intercostal zoster there may be ganglionic swellings in the infra- 
and supra-spinous fossae. The vesicles occasionally become gan- 
grenous in this and other varieties of the disease. 

Authors have established a number of clinical varieties of the dis- 
order, merely differing as to symptoms, such as acute febrile, apyretic, 
subacute, and even chronic and recurring forms. A bluish appear- 
ance of the eruption in some parts has suggested the name " black 
herpes ; n blood in the vesicles, a hemorrhagic form ; and the occur- 
rence of gangrene has added an additional distinguishing term. 

The anomalies of nervous significance are : extraordinary persist- 
ence of neuralgia after the involution of the cutaneous lesions ; neu- 
ralgia of an intense and intolerable severity at any period of the 
disease ; painful anaesthesia of the skin ; paretic and paralytic phe- 
nomena with resulting muscular atrophy ; and, in zoster of the head, 
dehiscence of teeth and hair. 

The vesicles of herpes zoster are always produced in the areas of 
integument supplied by sensory nerves proceeding from the cerebro- 
spinal tract, a circumstance which explains their usual limitation to 
a single lateral half of the body. This limitation is rarely observed 
exactly at the median vertical line of the body, as a few lesions can 
usually be seen surpassing this boundary. The terms zoster capitis, 
zoster brachialis, zoster occipito-cervicalis, etc., are used to distin- 
guish the special regions involved in the disease. 

The fact that the majority of all cases are due to disease of the 
ganglionic nervous system and not to disease of the spinal cord, ex- 
plains the more frequent occurrence of zoster in the upper portion of 
the body. 

Individuals are commonly subject to but one attack of herpes 
zoster in a lifetime, though, as usual for all general laws, there are 
the few exceptions which prove the rule. The same may be said of 
double attacks, those involving simultaneously the two lateral halves 
of the body, instances of which are occasionally recorded. These may 
be complete and symmetrical, or multiple and not symmetrical ; or 
bifid, when there is simultaneous involvement of several branches of 
one nerve or of several nerves. 

Barensprung recognized the nine varieties of this disease named 
below, the difference in each having a purely local significance. 

Zoster Capillitii depends upon involvement of the second 
branch of the fifth pair of nerves, and its lesions occupy the anterior 
and posterior portions of the scalp. 

Zoster Frontalis occurs in the area supplied by the supra- 
orbital nerve, which springs from the first branch of the trigeminus 



248 DISEASES OF THE SKIN. 

Its lesions extend from the upper eyelid to the vertex, and are 
spread in a fan-shaped figure over one-half of the brow, forehead, 
and scalp. 

Zoster Ophthalmicus may be a severe and dangerous manifes- 
tation of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye, even resulting in 
panophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. 
Typical cases of zoster of this region may not, however, exhibit a 
single untoward symptom of the disease. 

Zoster Facialis depends upon involvement of the sensory 
nerve-fibres of the trigeminus distributed to the face, its lesions 
being displayed over one cheek, the side of the nose, the half of the 
lip, or of the chin. The facial and seventh nerves may be chiefly 
affected. Care must be taken in cases of this variety not to con- 
found the disease upon the nose with acne, or painful tertiary 
syphilitic lesions, errors which have occurred. When the lower jaw 
is involved, there may be severe toothache, dysphagia, and fall of 
the teeth, with great resulting deformity. 

Zoster Nuch^], seu Collaris, occupies the region extending 
forward from the cervical vertebrae to the clavicle, or upward toward 
the occipital region and the auricle. 

Zoster Brachialis occupies the region from the last cervical 
and first dorsal vertebrae over the supra-spinous scapular region and 
the contiguous portions of the upper arm. Rarely, even the skin of 
the fingers and that over the first and second ribs is involved. It 
is a common and usually mild form of the disease, and character- 
ized by a peculiar isolation of the vesicular groups. It occurs also 
with lesions of exclusively brachial distribution. Thomson, of 
London, reports brachial zoster with involvement of the right inter- 
nal cutaneous nerve where two groups of vesicles appeared in the 
palm of the hand. 

Zoster Pectoralis is the most frequent form of the disease, 
from which its common name " shingles " originated. The eruption 
occurs below the first dorsal, covering the skin of the thorax as far 
as the lumbar vertebra?, extending from the spinal column behind to 
the sternal region in front. Two, three, or more of the intercostal 
nerves in this region are commonly involved, and the neuralgia 
resulting has been frequently mistaken for the pain of a pleurisy. 
Children are more apt to display this than any other variety of 
zoster. 

Zoster Abdominalis. — The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. It is usually 
much less pronounced in its features, and the exanthem less abundant 



HERPES ZOSTER. 249 

than in the variety of the disease last described. When constipation 
exists, defecation may be attended with considerable pain. 

Zoster Femoralis covers the buttocks and sacrum, and extends 
along the thigh, sweeping from behind forward and from above 
downward as far as the popliteal space ; in some cases involving the 
leg and foot. The penis, scrotum, labia, vestibulum vagina?, and 
anus may then exhibit unilaterally arranged vesicles. 

The scars left by zoster are characteristic. Not only are they 
limited to the seat of the original disease, but they h&ve a peculiar 
indented look, as if made by a nail-sett aud hammer. They are 
particularly angular in outline, and do not exhibit the dead-white 
color of many cicatrices. 

Etiology. — Herpes zoster occurs in both sexes, and in the young 
as well as the old, though it is rarely seen among infants. It seems 
to be somewhat under the influence of the seasons, as cold and damp 
weather serves to increase its frequency in those susceptible to it. A 
large list of other depressing agencies are named as effective in its 
production, such as : certain poisons, carbonic acid gas, belladonna 
and atropine (Mackintosh), arsenic (Baker, Dyce Duckworth, Hutch- 
inson) ; pyaemia, carcinoma, fever, measles (Gerhardt), pulmonary 
inflammations (including phthisis), septicemia, haemorrhages, trau- 
matism, and malaria. It has also followed vaccination, the passage 
of electrical currents, the extraction of teeth, an accidental prick by 
a thorn, the tapping of hydatids, and gunshot wounds of the body. 
Inasmuch as no one of these causes can be cited as certainly effective 
in all cases, it can merely be said that any influence sufficient to in- 
duce inflammation of a sensory nerve or its ganglion, may be followed 
by the objective signs of the disease. 

Pathology. — The disease exhibits in some cases unmistakable evi- 
dence of its association with a descending interstitial neuritis, but 
may be associated with any irritative action in any portion of the 
nervous tract from central to peripheral limit. The researches of 
Barensprung, Rayer, Wagner, Charcot, Kaposi, and others have 
demonstrated with sufficient clearness that in zoster there are always, 
at some point in the corresponding nervous tract (cerebral or spinal 
centres, ganglia, or the nerves themselves), pathological changes. 
These are : enlargements, hemorrhagic effusion, separation, soften- 
ing, or destruction of the nervous bundles, with hyperemia, infiltra- 
tion, and multiplication of the elements which surround the latter. 

Sometimes the ganglia and nerves are both reddened and swollen 
at the site of the inflammatory affection ; at other times the ganglion 
alone is large and soft, or fatty from metamorphosis of its cells. 
According to Curshmann and Eisenlohr, the process may begin in 
the bloodvessels of the nerve-sheath, as well as the peri-neural con- 
nective tissue, the nerve substance being quite intact. This is termed 
acute nodose peri-neuritis, as small nodules were recognized by them 
in one case along the cutaneous branches of the axillary nerve. 



250 



DISEASES OF THE SKIN, 



Lassar, 1 in a post-mortem examination of three cases, found the 
nerves thin, flattened, and of a transparent reddish-gray color con- 
trasting with the normal white. There had been desquamation to 
the extent of replacing the normal structure with connective-tissue 
elements. Similar changes were recognized in ganglion cells and 
fibres. 



Fig. 45. 




Longitudinal section of the third spinal ganglion of the right lumbar region from a case 01 
lumbo-inguinal zoster. a,a, ganglion, the black spots correspond with pigmented ganglion 
cells, the dark lines to engorged vessels ; a,b,c,d,e. fatty tissue surrounding the ganglion ; b,b, 
nerve filament divided longitudinally at the points of entrance and exit ; at c,c, divided per- 
pendicularly. (After Kaposi.) 

According to Biesiadecki and Haight, the cutaneous lesions origi- 
nate in the deeper portions of the rete, precisely as in other vesicular 
diseases. The exudate from the hypersemic corium, especially its 
papillary layer, presses upward into the rete, the epithelia of which 
are thus separated and vertically elongated. The serous exudation 
finally reaches a point where the horny layer is forcibly raised from 
its bed to form the roof of the vesicle. The mechanical destruction 
of the papillary layer of the corium by the hemorrhagic or puru- 
lent contents of the lesions results in a solutiou of continuity, which 
is healed only by granulation and the necessary formation of a cica- 
trix. 

Robinson, also, studying the same phenomena in the skin, finds 
the epithelia lengthening into bands by tension, the lacunae between 
them distended with serum and a few rouud cells. Often the vesicles 
form about the hair-sacs. As the exudation increases, the rete cells 
are progressively separated, and finally discovered free in the exuded 
fluid, though some, in changed form but still connected, may be 
found in the upper part of the vesicle. Except at the margin, the 
mucous and horny layers are separated by the exudation. At first 

i Centralbl. f. d. med. Wissensch., Dec, 1883. 



HERPES ZOSTER. 251 

niany-chanibered, the vesicle represents finally a single chamber filled 
with serum containing rete-cells and a few pus-cells, the latter in- 
creasing in number as the vesicle changes its type. Its base at first 
rests upon the lower portion of the mucous layer ; later, upon the 
corium itself where all signs of papillse are absent. In the vicinity 
of the vesicle the papillse and corium are infiltrated and the vessels 
dilated, this peripheral change not extending deeply into the corium. 
Beyond this area, however, which is infiltrated in a columnar-shaped 
region, usually about a hair-follicle deep in the subcutaneous tissue, 
Robinson has recognized a peri-neuritis characterized by a round- 
celled infiltration within and around the neurilemma. 

Leloir draws a distinction, which seems to have a basis in fact, 
between a zoster of purely tropho -neurotic origin, occurring in the 
area of distribution of a profoundly injured nerve ; and that form of 
the disease in which, if there be nervous and ganglionic changes, 
these are but superficial and transitory. The opinion is gaining 
ground that a disease which occurs as a rule but once in a life-time, 
must acknowledge some influence behind even its best marked altera- 
tions in the nervous system ; must, in other terms, resemble the spe- 
cific exanthemata. 

The fact that Yaldettaro and others have produced septic effects 
after inoculation of cultures of micro-organisms recognized in the 
pus obtained from certain vesicles in zoster, has led to the inference 
that there is also a septic form of the disease. 

Diagnosis. — The vesicles of herpes zoster are not rarely confounded 
with those of eczema. But the distinction between the two is always 
very readily established. In eczema there is itching but no neural- 
gia ; vesicles which tend to rupture spontaneously, and never persist 
as in zoster ; the eczematous lesions are also smaller, more acuminate, 
and rarely distinctly limited to the lateral half of the body. Herpes 
simplex is frequently recurrent, herpes zoster almost never ; herpes 
simplex is exceedingly liable to spread around the mucous outlets of 
the body, and on either side of the latter, while zoster only reaches 
such regions after extension from other parts, and is then almost 
invariably monolateral. Its lesions are, moreover, never grouped in 
the concentric circles of herpes iris. 

Treatment. — The indications to be met in the local treatment of 
herpes zoster are the protection of the vesicles from rupture, and the 
relief of pain. These ends are best accomplished by thickly dusting 
the entire surface affected with an opiated powder, such as Ander- 
son's powder, with the sulphate of morphia, two grains (0.133) to 
the ounce (32.) ; lycopodium with powdered opium, etc. Rupture of 
the lesions should never be practised. Over the whole should be 
gently laid a sheet of soft lint or antiseptic cotton, its meshes also 
filled with the powder, and a bandage, when practicable, smoothly 
bound over the whole. In the milder cases, nothing more than this 
is needed from first to last. In others, where the lesions have rup- 
tured and their bases undergone erosive or ulcerative changes, the 
oleated lime-water with zinc oxide, belladonna and opium, or morphia, 



252 DISEASES OF THE SKIN. 

should be applied and covered with the Lister protective. Carbo- 
lated and anodyne ointments may also be used, especially toward the 
latter part of the history of the case. 

Lotions may be employed of lead-water and laudanum, or the 
" lead and opium wash." Van Harlingen recommends half au ounce 
(16.) each of the precipitated zinc carbonate, powdered zinc oxide, 
powdered starch, and glycerin, shaken up in half a pint (256.) of 
water. 

Duhring speaks well of collodion with morphia, in the strength of 
ten grains (0.666) to the ounce (32.). Kaposi warns against the use 
of the diachylon ointment. Generally, it may be said that ointments 
should be the last resort ; but those containing from ten to twenty 
grains (0.66-1.33) of the aqueous extract of opium or belladonna to 
the ounce (32.) will at times give relief from pain. The oleate of 
cocaine and menthol have been used locally with great advantage in 
meeting the same indication. 

No remedy, for internal use, is known to have the power of 
aborting or shortening an attack. Quinine is certainly indicated 
and does no harm ; but quinine and strychnia alike in full doses 
have proved quite inefficacious. Other remedies employed are the 
phosphide of zinc in one-third of a grain (0.022) doses, repeated 
every three hours, and, if indicated, in combination with one-sixth 
(0.011) of a grain of the extract of nux vomica ; arsenic (Kaposi) ; 
and the tonics in general. Anodynes, by the mouth or by hypo- 
dermatic injection, are often indispensable. Inasmuch as many 
patients consider the attack a trivial matter, it is of some consequence 
that they be warned of the possibilities of the future and be confined 
to an apartment of equable temperature where they are not exposed 
to atmospheric changes. This is of special importance in all the 
zosters of the face. A skilled oculist should be consulted in all cases 
involving the eye. 

Other measures useful are : first in value and importance, a con- 
tinuous galvanic current of between two and three milliamperes, two 
or three times daily for ten minutes at a sitting ; next, blistering or 
dry- or in sthenic cases wet-cupping over the root of the nerve ; lastly 
a dry dressing with biniodide wool. The stronger applications 
recommended of late (ninety per cent, alcohol); or, resorcin two parts 
alcohol one hundred parts ; or one per cent, of menthol or thymol, 
may be useful when other measures fail. Asa rule the exanthem in 
zoster is preferably dressed dry and amply protected with lint, medi- 
cated wool, or an impermeable tissue. 

Prognosis. — Zoster usually runs a benign course. The prognosis 
may be, in exceptional cases, in the highest degree grave. Many 
severe cases have occurred, where patients, after years of intense 
suffering, have resumed the occupations of life, physical wrecks of 
their former selves, their faces indented with profound scars, and the 
vision of one eye impaired or utterly ruined. Rarely the termina- 
tion is fatal. 



DERMATITIS HERPETIFORMIS. 253 



Dermatitis Herpetiformis. 

Dermatitis Herpetiformis is a rare but well defined febrile disorder, characterized 
by the appearance upon the skin, of multiform lesions, differing in different 
cases, macular, papular, vesicular, pustular, or bullous in type, attended by 
subjective sensations of itching and burning, the disease at times being grave 
in character and fatal in termination. 

Dermatitis Herpetiformis should be named Dermatitis Multiformis, 
as the latter term is more descriptive of its phenomena. It is a 
malady which, in one form or another and under different titles, has 
long been recognized aud described. The credit, however, of clearly 
establishing its identity, and of recogniziug oue process as differently 
expressed in the several observations of others, is largely due to Dr. 
L. A. Duhring, of Philadelphia. 1 

The identity of the disease as a special pathological process has 
been only lately established. Much investigation is yet required 
before settling definitely many of the interesting questions it presents 
for consideration. Duhring regards its vesicular and bullous forms 
as identical with " herpes circinatus bullosus " (E. Wilson) ; " pem- 
phigus prurigineux " (Hardy) ; " herpes gestationis " (Milton, Bulk- 
ley, and others); " pemphigus" (Klein); "pemphigus circinatus" 
(Rayer) ; " herpes phlyctsenodes " (Gibert) ; " pemphigus aigu pruri- 
gineux " (Chausit) ; " herpes iris " (Jarish) ; " fatal pemphigus-like 
dermatitis " (Mayer) ; " peculiar skin eruption recurring during 
pregnancy" (Oswald); "bullous eruption of a peculiar character" 
(Leigh) ; " pemphigus compose " (Devergie) ; and " hydroa " (Jones, 
Bulk ley, and others). 

Symptoms. — The disease is usually announced by malaise, sensa- 
tions of chilliness, decided rigors or alternations of cold and hot 
sensations, with systemic disturbances. The skin usually is then the 
seat of pruritic or burning sensations followed in the course of from 
twelve hours to two days by the appearance of the exanthem. This 
may be macular, papular, tubercular, vesicular, pustular, or bullous, 
in type ; combinations of these lesions recurring in every variation. 
The lesions may be cutaneous, mucocutaneous, or mucous in situa- 
tion. 

The macular form of eruption appears in small-coin to palm- sized 
patches, irregularly rounded, coalescing, well or ill-defined as to 
outline, and slightly raised, suggesting the lesions of erythema multi- 
forme or urticaria. Imperfectly defined maculo-papules, papules, and 
papulo-tuberculous lesions, varying in shape, size, and firmness may 

1 Dermatitis Herpetiformis ; its relation to so-called Impetigo Herpetiformis. Amer. Journ. 
of the Med. Sci., October, 1884. 

Dermatitis Herpetiformis, case of, caused by nervous shock, etc. Ibid., January, 1885. 

Case of Dermatitis Herpetiformis, illustrating the pustular variety of the disease. Journ. of 
Cutan. and Ven. Dis.,vol. i., No. 8. 

Case of Dermatitis Herpetiformis with peculiar gelatinous lesions. The Med. News, March 
7, 1885. 

Notes of a Case of Dermatitis Herpetiformis, etc. N. Y. Med. Journ., November, 1884. 

A Case of Dermatitis Herpetiformis (Bullosa). N. Y. Med. Journ., July, 1884. 



254 DISEASES OF THE SKIN. 

also spring from or be intermingled with the reddish maculations 
described above. 

In typical development the disease, however, presents cutaneous 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pin-head to bean-sized, 
tensely distended with their contents. They may be pale-yellow or 
darker in color, and with or without areola?. When bulla? form, they 
may be sparse or plentiful, and bean- to egg-sized, with cloudy,, 
lactescent, hemorrhagic, or purulent contents. Pustules, when pres- 
ent, are single or clustered, pin-head to bean-sized lesions, flat, and 
surrounded by a livid areola. "When evolution is complete, segments 
of rings, or distinct rings of new punctate or large pustules surround 
those first formed, which in less than a week rupture and become 
covered with a crust, the latter being flat, adherent, and yellowish, 
greenish, brownish, or blackish in color. When there is coalescence, 
a large coin-sized pustule and crust may result, and even large 
patches of such coalesced lesions. The lesions may number from a 
score or fewer to hundreds. 

The imprint of the cutaneous symptoms* is multiformity and recur- 
rence. Vesicles, pustules, and bulla?, without order or regularity of 
evolution or recurrence, appear at one and the same time, in rapid or 
slow succession, and without fixed intervals of appearance for months 
at a time. Generally, however, a prevalence of one special type of 
lesions may be noted during a single period of out-break or recur- 
rence. This prevalence is in the direction generally of lesions of an 
herpetic type, viz., the vesicular and the bullous, in variously sized 
patches with a tendency to coalesce. 

As a result of the conditions described above, a peripheral new 
formation of lesions tends to produce marginate patches where group- 
ing occurs, the groups, however, being interspersed with diffusely 
disseminated lesions of various types. The irregular, angular, or 
stellate forms of the lesions containing fluid, are highly suggestive. 
Pigmentation and infiltration of the skin are commonly noticed. 
The subjective sensations of burning increase and diminish as cuta- 
neous lesions are multiplying or disappearing. The pruritus is in 
some cases more severe than in eczema, and the traumatisms of 
scratching add greatly to the multiform features of the disease. 

The disease lasts for months and years. Duhring reports some 
cases lasting for five to fifteen years, with periods of relative or entire 
immunity. 

In one of Duhring's cases there were thumb-nail sized, raised but 
flat, golden-yellow colored lesions, of very firm consistency, contain- 
ing a similarly colored, thick, consistent, gelatiuous pulp. The 
author states that he has observed them before in several cases of 
this same disease. 

When the oral cavity is invaded, pustules and bulla? appear upon 
the mucous surface which, being macerated and sodden, rupture, 
leaving raw and unhealthy looking erosions, even sloughing patches 
of mucous membrane. Crusts form about the nares and lips, and 






POMPHOLYX. 255 

the stench of the patient becomes intolerable. In the same way the 
vulva, anus, and prepuce may be surrounded by vesicular and bullous 
lesious which form also on the mucous surfaces adjacent, and pursue 
a course similar to that recognized in the mouth. 

In grave cases, as the skin symptoms exhibit a marked aggrava- 
tion, the systemic condition changes for the worse. After a low 
fever alternating with chills and accompanied by progressive cachexia 
and emaciation, an intermittent diarrhoea or pneumonia may close 
the scene. The repulsive appearance of the patient at the last is, in 
severe cases, as formidable as in the fatal issues of confluent variola 
or severe pityriasis rubra. 

The etiology, pathology, and proper mode of treatment of this dis- 
ease are not yet fully understood. In some cases disorders of the 
nervous system must be admitted as efficient in its production. 
Duhring reports a typical case following nervous shock. One of my 
patients had lost a number of children by accident. The disease 
occurs in early and middle adult life in both sexes, though in women 
decidedly oftener than in men ; and, among the former, preferably 
among those in the puerperal and pregnant states. Unquestionably 
the phenomena of the disease in the later stage of fatal cases are 
septicaemic in origin. 

Internal treatment in general has been directed to meet the indica- 
tions presented. Thus, quinine, the mineral acids, ergot, saline 
laxatives, iodide and bromide of potassium, arsenic, and chloral, 
have all been administered without appreciable effect upon the dis- 
ease. Locally, carbolic acid, tar lotions, the unguentum diachyli 
albi, of Hebra, mercurial and zinc salves have all been employed. 
One of Duhring's patients experienced great relief from the use of 
a sulphur ointment. Two of my patients were treated with very 
great comfort to the end in the continuous warm-water bath. 

The prognosis is always doubtful and generally grave. It is not 
certain that the disease is ever completely relieved. A male patient, 
seen by me on consultation and then presenting the typical features 
of the disease, was reported well after one year. 

Pompholyx. 

Gr., 7rofi66/.v$;, a bubble. 

(Cheiro-pompholyx ; Dysidrosis.) 

Pompholyx is an affection of the hands and feet chiefly, characterized by the 
occurrence in these regions of vesicular and bullous lesions of persistent type. 

The disorder described by the title given to this chapter has been 
the occasion of no little medical controversy. Observers are still 
not agreed as to its nature and identity. In the latest edition 
of his valuable work Kaposi asserts that the symptoms described 
below are those simply of acute eczema. Tilbury Fox, Hutchinson, 
Robinson, and others have made exceedingly careful studies of the 



256 DISEASES OF THE SKIN. 

disease. I have had a number of patients in charge, all presenting 
symptoms of special character. The paragraphs devoted to dysidro- 
sis in this work, are intended to call attention to the disease as it 
occurs in connection with the affections of the sweat- or coil-glands. 

Symptoms. — The disease affects simultaneously and as a rule sym- 
metrically the hands and feet ; if either organs are spared it is com- 
monly the two feet. One side may be worse than the other. The 
eruption is preceded or accompanied by burning or tingling pain, 
and is characterized by the appearance on the dorsum or sides of the 
fingers or over the palms and soles or over the whole hand or foot, of 
deeply set, single or numerous, grouped or confluent vesicles, or 
vesico-bullse. According to Fox, annular collections of fluid may 
be seen about the sweat-pores. The appearance of well-developed 
lesions is compared to that of boiled sago-grains imbedded within the 
skin. When the bullae attain an extreme development, the distended 
lesions project from the skin as large as pigeon's eggs, irregularly 
outlined and containing a neutral or alkaline fluid, translucent or 
turbid, and seated on an cedematous, often exquisitely painful and 
sensitive, skin. They are said not to rupture spontaneously but to 
undergo absorption in a fortnight or more, with exfoliation of the 
loosened epidermis, but there are well-marked exceptions to the rule. 
Beneath the purposely ruptured bullae is a new-formed and reddened 
or exfoliating and sodden (which under favorable circumstances be- 
comes later a sound) epidermis. The hyperidrosis mentioned by 
some authors may or may not be a prominent feature in the case of 
affected patients before and during the occurrence of the disease. 
There may be recurrent attacks in consecutive seasons; and also 
recrudescence of the disease in the affected. It occurs in both sexes ; 
apparently more often in women in England ; in America, I believe 
that more male patients have suffered. The ages of the latter are 
from those of childhood to middle life ; I once treated a well- 
marked case in a man of sixty. The sufferers with but few excep- 
tions, are in poor health ; broken down from nervous overstrain ; 
neurasthenic rather than cachectic. 

Pathology. — The differences among observers respecting the char- 
acter of the disease depend upon whether the view is taken with 
Fox, Crocker, and others, that the vesicles lie directly connected with 
or in the line of the sweat-duct ; or whether, with Hutchinson, 
Robinson, and others, no connection with the coil-glands is recog- 
nized, the vesicles lying in the superior portions of the rete over the 
papillae and not in the rete pegs which pass below to meet the duct 
of the coil-gland. Crocker, however, found some lesions in both 
situations. 

Diagnosis. — The disease is to be differentiated from eczema which 
it certainly does not resemble. The tendency of the vesicles to per- 
sist and after intentional rupture, not to furnish from the former 
floor a serous exudate, is strikingly different from the course of 
eczema. Again, there is seldom, if ever, in well-marked pompholyx, 
a tendency to change in type from a serous to a pustular exudation. 



psoriasis. 257 

Lastly eczema of the palms and soles is almost invariably of ery- 
thematous type. 

The internal Treatment of these cases is of importance. Patients 
require the best climatic and hygienic environment and mental dis- 
traction. In the way of medicaments, quinine, nux vomica, steel, 
and the mineral acids ; or, when especially indicated, cod-liver oil, 
matzool, and koumyss may be needed. The local treatment is by 
employment of the Lassar paste covered with boric or salicylated 
powders ; or by the application of strips of muslin spread with lead 
or zinc salves. 

Psoriasis. 

Gr., ipcopd, the itch. 

(Lepra, Alphos, Psora. Ger., Schuppenflechte.) 

Psoriasis is a cutaneous disease, acute, or, more usually, chronic in course, charac- 
terized by masses of whitish, lustrous, and adherent scales, in pinhead-sized 
agglomerations upon the surface of the skin, or in larger disks resting upon 
circumscribed, usually circular and reddened patches of epidermis, which are 
readily made to bleed. 

Symptoms. — In psoriasis the primary lesion is a punctiform macule 
of reddish-brown tint, always at the earliest moment of observation 
covered with a delicate, whitish, epidermic scale. When this is 
removed, even by gentle scraping, one or more minute droplets of 
blood exude from the points beneath which lie the vascular papilla? 
of the corium. When several or many such small points are visible 
upon the surface, the disease is called Psoriasis Punctata. 

Should the disease progress to fuller development, patches of larger 
size form, always with a definite contour, very slightly elevated above 
the general level of the integument, and covered with whitish, 
mother-of-pearl-colored scales in abundance. When these are about 
the size of drops of water, the disease is termed Psoriasis Guttata. 

In yet more advanced conditions of the disease other names are em- 
ployed, all suggested by the external configuration of the patches, none 
having any pathological significance. Thus Psoriasis Nummularis. 
is characterized by coin-sized patches; Psoriasis Circinata, or 
Orbicularis, by patches where the disease is actively exhibited at the 
periphery of a circle, in the centre of which the scales have dis- 
appeared : Psoriasis Gyrata and Figurata, by coalescence and 
extension of several patches, forming thus fantastic figures covered 
with grayish- white, imbricated scales ; and Psoriasis Diffusa, by 
much more extended and uniform involvement of the skin in large 
areas. 

The greatest variation is exhibited in the progress of the disease, 
and to this point special attention should be directed. Thus, in a 
single individual the eruption may appear upon one or more regions 
of the body in the form of the punctate lesions described above, and 

17 



258 DISEASES OF THE SKIN. 

thereafter regularly progress through the degrees suggested by the 
list of names given above, till the entire surface of the body is com- 
pletely covered from the crown of the head to the soles of the feet. 
This is fortunately very rare, and indeed denied by some observers. 
I have never seen a case where a few square inches of sound skin could 
not be discovered at some point of the bodily surface. More often 
the eruption tends to remain stationary when one or another of the 
less extensively developed phases of the disease has been displayed. 
Thus the patches may be at no time larger than a silver quarter of a 
dollar, and though very numerous, fail for years to extend beyond 
such a limit. They may even persist for a longer period in even 
smaller dimensions, or, what is perhaps more common, occur in gut- 
tate forms upon the chest, and in patches as large as the palm over 
the knee or sacrum. 

The sites of preference of the disease are over the extensor surfaces 
of the extremities, especially about the elbow and knee, where it is 
decidedly most common. After these locations should be named in 
order, the region of the sacrum (where often the largest patch upon 
the body can be discovered), the upper surface of the chest, the scalp, 
the face, the belly, and the genitals ; more rarely the hands and feet. 

The disease is essentially chronic in its course, is^never contagious, 
and the efflorescence does not usually awaken any subjective sensation. 
Its features are so pronounced in typical cases that its recognition is 
facile, after appreciating the number and distribution of the patches, 
their clean-cut outline, the unaltered integument between the lustrous 
and shining scales, and the red border of the skin which may crop 
out from beneath the squamous thatch above, or be completely hidden 
by the latter. Rarely a single isolated patch betrays the existence of 
the disorder. 

When the disease is acutely spreading over the surface it has occa- 
sionally a different expression. This is often seen in young adults. 
The patches are perhaps as large as the section of a hen's egg ; dark 
or lurid-red over the whole ; covered with a more uniformly con- 
stituted, thin, squamous film, or sheet of semi-transparent delicate 
membrane, through which the red glare of the patch beneath is 
visible. This condition may also be seen in young persons to whom 
arsenic has been administered for the relief of the disease, with the 
production of irritative effects. 

In its indolent moods, the color of the patch varies somewhat with 
the hue of the patient's complexion. Blonde women with flaxen hair 
and clear tint of the iu tegument, often exhibit singularly waxy-whitish 
patches, decidedly differing in color from those occurring upon the 
muddy and greasy integument of certain dark-skinned men. 

The scales are usually abundant, and may adhere with considerable 
firmness to the patch, or, more frequently, be shed freely from the 
surface, in pronounced cases powdering the clothing of the patient or 
the sheets of the bed upon which he reposes at night. 

There is never at any time in the course of the disease, the appear- 
ance of other lesions or their sequela?, such as vesicles, pustules, crusts, 






psoriasis. 259 

papules, tubercles, ulcers, or any discharge-feature. The eruption is 
dry from first to last. Exception only may be made in the case of 
patches occurring where motion of the skin produces fissure, an acci- 
dental and by no means characteristic complication. The same may 
be said of certain acute symptoms, especially developed in young and 
tender skins, where considerable redness, occasionally with an ery- 
thematous halo, appears in and about individual patches, with the 
production of itching, heat, burning, pain, or other disagreeable 
sensations. 

The involution of the disease is evident in a gradual cessation of 
the scale-formation and the exhibition of a normal epidermis which 
gradually spreads from the centre, or is at once perceptible over the 
entire surface of the patches. No cicatrization results. 

Upon the scalp, plaques of well-defined contour, covered with thick 
whitish scales, may mat the hairs together, but alopecia almost never 
results. The dry condition of these scales contrasts with the greasi- 
ness of the crusts formed in seborrhoea of the scalp. Often a fillet 
or band of diseased tissue, one or more inches in width, projects be- 
yond the border-line of the scalp and forehead. When the vertex is 
bald from physiological loss of hair, the patch of psoriasis usually 
lingers near the fringe of the hairs left at the sides of the head, pro- 
jecting thence to the regions of baldness. On the face as well as 
over the genitals, the lesions are usually both indistinct and small- 
sized, displayed, as regards the former locality, over the cheeks, chin, 
and nose, avoiding the parts near the mucous orifices. When there is 
much vascular congestion, especially of the passive kind, the patches 
assume a violaceous or purplish tint. All forms of lesions are seen 
upon the trunk, especially over the dorsum and near the sacrum ; the 
patches, in well-marked cases, encircling the body in ill-defined par- 
allels reaching from the spine forward. The hands, feet, fingers, and 
toes are not often involved, and the palms and soles only, so rarely 
as to throw doubt upon a diagnosis based upon the existence of the 
disease solely in these regions. In severe cases, the nails are second- 
arily involved, being thickened, eroded in points, irregularly lamin- 
ated, rigid, and becoming brittle and yellowish-white or dirty-whitish 
in color. 

The amount of scaling varies greatly in different persons and in the 
same individual ; sometimes the scales are abundant and thickly heaped 
up over even small areas ; sometimes they are sparse over large areas. 
In acute febrile and other intercurrent diseases the disorder may fade 
or disappear. Where the epidermis is thin, the scaling is less ; there- 
fore, in youth, over flexor surfaces, near the mucous orifices, and on 
the back of the hands, the scaling is less than in advanced years, over 
extensor surfaces, in regions remote from the mucous orifices, and on 
the palms and soles. The disease may be for years limited to two or 
three continuously existing patches, or, what is far more common, 
recur at irregular intervals and under varying circumstances. As a 
rule, it is worse in winter and in cold climates, though patients may 
demonstrate the reverse of this. 



260 DISEASES OF THE SKIN. 

The scales may display, instead of a lustrous white, a deep yellowish 
shade, and instead of being imbricated, form a thin, continuous sheet 
of exfoliated epidermis. When the disease is disappearing, the scales 
fall, leaving a pigmented or slightly discolored patch of integument. 

A rare ultimate termination of the disease is the formation of 
verrucous growths in the psoriatic patches, which later become 
epitheliomatous. 1 At times the eruption is the source of excessive 
annoyance, beiug the seat of intense pruritic and burning sensations 
of a persistent type. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which it is difficult to determine whether 
the two disorders coexist, or the one has assumed the features of the 
other. In these cases, there is itching and infiltration of the skin, 
with vesicular and other lesions foreign to psoriasis, and a catarrhal 
discharge. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called " psoriasis linguae," are those of " leucoplakia buccalis," 
of "smokers' patches," of syphilitic disease of the mouth, or flat 
epitheliomata. 

Etiology. — The causes of psoriasis are not known. As no external 
or internal factors can be demonstrated to be effective in its produc- 
tion, it is safest to conclude that these unrecognized sources of the 
affection are limited to the skin itself. The disease is neither con- 
tagious, hereditary, nor limited to either sex, occupation, or social 
condition. It bears no relation whatever to syphilis, eczema, gout, 
rheumatism, struma, or dyspepsia. It appears in the feeble and 
delicate as in the most superb specimens of manly vigor and womanly 
beauty. Though not occurring in infancy, it yet usually first appears 
in early life. Kaposi reports a single case in which the eruption 
appeared in the eighth month, and Eliot, a case of first appearance at 
the eighteenth month of life. Under these circumstances, the question 
arises : Is this affection of the integument, when uncomplicated by 
the disagreeable symptoms named above, a disease or a deformity ? 
Certainly in a very large number of individuals, displaying through 
life unchanging patches where the characteristic symptoms are the 
same year after year, the ailment would seem to be more properly 
classed with the deformities than with the diseases of the skin. In 
point of frequency, the eruption ranks next after eczema. 

No child was ever born psoriatic, yet believers in the possibility 
of the transmission of the disease by inheritance are numerous, 
and some of them careful observers. Robinson goes so far as to say 
that in the a majority" of all cases there is an inherited predisposi- 
tion to the disease. Others conclude it to be an inherited or trans- 
mitted form of syphilis, struma, tuberculosis, rheumatism, or gout. 
Weyl thinks that inheritance may possibly be the sole cause. 
Bazin admits the existence of both an herpetic and an arthritic 
psoriasis. 

1 See Dr. J. C White's paper, American Journal of the Medical Sciences, 1885. 



PSORIASIS. 261 

Bearing in mind the relative frequency of psoriasis on the one 
hand, and on the other the strict tests which should be applied in 
order to prove that a disease is actually transmitted by heredity, we 
find that the doctrine of heredity in psoriasis fails of establishment. 
It is putting a low estimate on the actual figures to state positively 
that there are more than one thousand psoriatic patients in this 
country, no one of whose ancestors, so far as known, ever had 
psoriasis, syphilis, or rheumatism. They furnish too large a body of 
evidence to be either ignored or set aside with a word. Thousands 
of their children are living to-day free for years from any evidences 
of disease. They, too, call for further proof on this point. 

It has long been known that in psoriasic subjects lesions may be 
artificially developed in the Hues of mechanical irritation. In this 
way, figures in the shape of anchors, crosses, hearts, etc., have been 
produced on the skin of psoriasic patients, one of which has been 
ingeniously photographed by Dr. Fox, of New York. 1 The disease 
has been also attributed to vasomotor neurosis ; to fright ; to shock, 
and to neuralgias. 

The disorder is rather more common in male than in female patients, 
and appears to be rare in the negro races. According to Greenough's 
statistics, it represents about two and a half per cent, of all cases of 
cutaneous disease. It has followed vaccination, scarlet fever, and 
other diseases. 

Dr. Gowers alone reports the artificial production of psoriasis by 
the internal administration of the biborate of sodium. Allusion has 
been heretofore made to this circumstance in the chapter on Dermatitis 
medicamentosa^, v.). Further evidence would be required to estab- 
lish the fact that these results differed to any appreciable extent from 
those recognized in any squamous dermatitis produced by an ingested 
drug. 

I believe that in some cases the disorder is due to the exclusion of 
sunlight from the portions of the body covered with the clothing and 
the hair. Certain it is that it is only in extreme cases that the face 
is attacked at a distance from the line of the hairs upon the brow 
and the bearded region (sides of the nose, cheeks, temples). It is also 
true, that exposure to abundant sunlight of these parts, not only when 
patients are intentionally treated by such exposures of the nude body 
to light in hospitals and private practice, but in the occupations 
that necessitate the same, beneficial results are often well-marked. 

Pathology. — The observations of Wertheim, Neumann, Auspitz, 
Kaposi, and Robinson, of New York, are substantially in accord 
respecting the general character of the changes occurring in the course 
of the disease, though they differ upon the question whether it depends 
upon an inflammatory or purely hyperplastic process. So far as this 
problem is illuminated by clinical facts, it would seem clear that both 
views are correct, the disease being at times unquestionably the result 
of a circumscribed inflammation ; at others associated with a simple 

1 In his admirable Photographic Illustrations of Cutaneous Diseases. New York, 



262 



DISEASES OF THE SKIN. 



overgrowth of the elements of the epidermis ; and again at times with 
an inflammation which the hyperplasia has awakened. There is 
always abundant development of the epithelia in the rete, and, in 
recently formed patches, distention of the blood- and lymph-vessels in 
the papillary layer of the corium beneath. In older plaques the rete 
either dips downward to an unusual extent between the papillae, or 
the latter push upward in the manner of wart-like prolongations. It is 
reasonable to conclude that at times both hypertrophies concur. The 
corium is thickened later by an increase of its elements which may 
involve its entire width as far as the connective tissue. In the older 



FIG. 46. 



j y hi -**- 1- .- — ' - — ' 




Vertical section of skin from a patch of psoriasis of long standing. MP, Malpighian prolonga- 
tion ; C, corium ; L, leucocytes. (After Jamieson.) 

plaques also the connective tissue elements are often separated by a 
slight serous infiltration. Hyper-pigmentation is also noted. The 
external root-sheath of the hairs in direct connection with the rete 
participates in the same process, thus explaining the defluvium capil- 
litii of certain cases, and the resulting transient or permanent baldness. 
The sebaceous glands are secondarily involved in the scalp only. 
Lang, 1 of Innsbruck, has attracted notice by his alleged dis- 



Viert. f. Derm. u. Syph., 1878. 



psoriasis. 263 

coveiy of certain fungous elements in psoriasis, which he claims to 
be the cause of the disease. These he finds in the whitish pellicle 
beneath the superficial squamous layer, to which Bulkley had 
already called attention. After stripping this pellicle or a part of it 
from the surface, and subjecting it to the action of a five per cent, 
solution of caustic potash, the epithelium becomes translucent, and 
upon and beneath the latter double-contoured and highly refractive 
spores become visible. Lang considers this to be a fungus of the 
lowest species, different from any previously recognized upon the 
skin. He terms this " epidermo-phyton." In his treatment of 
psoriasis the author proceeds upon the principles which govern the 
management of the other dermato-mycoses. He considers that the 
value of the remedies hitherto found most useful in the disease, such 
as tar, carbolic acid, chrysarobin, and the mercurials, owe their 
efficacy to their destructive action upon the fungus. He has used 
with advantage a topical application of rufigallic acid in a salve, one 
part in ten. 

Weyl, who believes that psoriasis is due to u an inherited weak- 
ness of the nervous centres," has seen Lang's " brood-cells," and 
regards them as " myelin-like exudations ; " but this position is 
disputed by both Wolff 1 and Eklund, 2 who confirm Lang's observa- 
tions, and believe the disease to be of parasitic origin. They explain 
the artificial production of psoriatic patches in the psoriatic skin, by 
supposing spores to have been deposited beneath the skin, and not 
previously awakened to activity in the sites of such experiments. 

Lassar 3 has succeeded in producing a disease of the skin in rabbits, 
by rubbing into various portions of their bodies, scales, blood, and 
lymph removed from psoriatic patches in a male patient. The 
disease thus induced is capable of transmission to other animals. 
Campana, Tommasoli, and other Italian observers, have repeated 
these experiments, with the result of reaching the conclusion that 
psoriasis is produced by a parasite as yet unrecognized. 

Diagnosis. — The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical forms of the eruption which occasion 
doubt. It is to be distinguished from : 

Eczema. — Eczema and psoriasis differ in a striking manner with 
respect to their sites of predilection, and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous 
outlets, the flexor faces of the joints and limbs, the crevices, folds, 
pockets, depressions, and protected angles of the skin. Psoriasis 
elects the posterior surfaces of the body, avoids the vicinity of the 
mucous outlets, spreads abundantly over the extensor aspect of the 
joints and extremities, and enjoys the regions of pressure and friction, 
as the skin over the patella and the olecranon process of the ulna. 

1 Viert. f. Derm. u. Syph., 1884. 2 Annal. de Derm, et de Syph., 1885. 

3 Deutsch. med. Zeitg., 1885, No. 93. 



264 DISEASES OF THE SKIN. 

Psoriasis, covering the vertex and scalp, lingers at the brow, where 
its scaly thatch stretches from side to side close to the line of the 
hairs, and creeps more indistinctly down the face on either side in 
front of the ear, reluctant to spread over the cheeks, nose, and lips. 
Eczema easily escapes from the scalp to the nose, lips, or chin ; or 
lurks in the folds of the pinna of the ear. Psoriasis will cover the 
back and reach forward in front by almost symmetrically disposed 
parallels in the direction of the ribs, while eczema sweeps between 
and beneath the breasts or around the nipple. Psoriasis may cover 
the belly and spare the navel and pubes, where eczema may originate. 
As before stated, the largest patch of psoriasis on the body will often 
be discovered over the sacrum, while eczema creeps upward with a 
diminishing vigor from the anus between the cleft of the nates. 
Psoriasis often spares the hands and feet, which eczema punishes. 

In individual patches eczema will be recognized by its severe 
itching ; the scratching it excites ; the history of moisture, discharge, 
and crusting ; its ill-defined outline ; its asymmetrical disposition, 
except upon the similarly irritated hands aDd feet ; and the fewer, 
more yellowish, smaller, and less lustrous scales which characterize 
its squamous varieties. 

Favus of the scalp might be mistaken for psoriasis of the same 
region, but the occurrence of sulphur-colored, cup-shaped crusts, the 
existence of the parasite, the lustreless and brittle condition of the 
hairs, and a possible history of contagion, will insure identification 
of the former. In psoriasis, too, the hairs are usually firmly at- 
tached in their follicles, while they are loosened in favus. 

Lichen Ruber Acuminatus, though a very much rarer disease 
than psoriasis, must in cases be carefully recognized as distinct from 
the latter. In it the lesions are papular, distinct, covered by few 
scales, and these yellowish in color, never lustrous. There is always 
a constitutional impairment of health, and, when the whole epidermis 
begins to break up in scales, a condition of well-marked marasmus. 
When scratched, the patches of the disease do not bleed. Finally, 
lichen ruber tends to a fatal termination. 

Lichen Ruber Planus. — In this disorder the scales are at the 
outset attached to the apices of minute polygonal papules, and these 
on the flexor rather than on the extensor aspects of the extremities 
where psoriasis is more abundant. The patches in well-marked 
cases of lichen planus have a characteristic crimson-red or purplish 
hue, rarely lacking and never perfectly seen in any case of psoriasis. 
The scales, further, of lichen planus are of a very characteristic silver 
whiteness never perfectly seen in psoriasis, though imitated by the 
yellowish-white or pearl-white hues of the latter. Lichen planus 
never appears in oval or roundish patches, but is peculiar among 
all dermatoses in its angular, linear, and even stellate arrange- 
ments. 



psoriasis. 265 

Lupus Erythematosus. — In any doubtful case where cicatricial 
tissue is discovered in the site of a patch where the disease has 
existed, the diagnosis is clear, since psoriasis never leaves a scar. 
Lupus prefers the nose, the cheeks, and other parts of the face com- 
monly spared by psoriasis unless it be very abundant elsewhere. 
The lupus scales are scanty, firmly adherent, yellowish, and attached 
to the orifices of the ducts of the sebaceous follicles ; those of 
psoriasis are abundant, lustrous, and shed freely from the surface. 
Lupus is almost never, like psoriasis, a generalized eruption ; and is 
always much more chronic in course. There is a bluish and 
violaceous tint to the reddish patch of lupus erythematosus, espe- 
cially as it occurs upon the face, while the highly colored patches of 
psoriasis are rarely facial, being more commonly seen on the trunk 
and extremities, while the outcropping disks on the face are the least 
colored of any on the body. 

Pityriasis Maculata et Circlnata. — In this disease the 
patches are more oval than circular, and the scales much finer than 
in psoriasis. It is, moreover, much more rapid in its career and does 
not recur. When the branny scales are removed, the surface beneath 
does not bleed. The centre of the patch is usually tawny or salmon- 
colored. The thoracic surface may also be exclusively involved. 

Pityriasis Rubra. — If psoriasis be in any case generalized, its 
distinction from pityriasis rubra would be difficult, if not impossible, 
on the basis of our present knowledge. Indeed, any such distinction 
would have but little practical value. A few typical isolated 
patches of a psoriasic character would point to the origin of the dis- 
ease in any doubtful case. 

Seborrhcea. — This disease could only be confounded with psori- 
asis of the scalp. But the last-named affection is, in the vast 
majority of cases, exhibited also in patches upon other portions of 
the body where seborrhoea is never seen. Seborrhcea of the scalp 
also occurs in usually diffuse forms, the surface beneath the crusts 
being rather anaemic and pallid in appearance, not bleeding readily, 
as in psoriasis. The crusts, too, in seborrhoea, are distinctly fatty 
aucl greasy when rolled between the fingers, and have a dirty- 
yellowish hue, never recognized in the whitish scales of psoriasis. 
Lastly, seborrheic crusts may fringe slightly the line of the hairs at 
the brow, but never form a band an inch or more in width, like a 
frontlet covering the upper half of the forehead, a not uncommon 
development in psoriasis. 

Syphilis. — Psoriasis does in many cases greatly resemble the 
squamous and papulo-squamous syphilides. The necessity for a 
clear recognition of either disease occurring in suggestive patches is 
often of the highest importance. 

In syphilis the greatest aid will be obtained by a history in both 
sexes, of infection, adenopathy, and mucous patches ; and of abortions, 



266 DISEASES OF THE SKIN. 

miscarriages, or still-births in women. Psoriasis is a singularly 
uniform disease ; syphilis decidedly multiform in its manifestations. 
The syphilitic patches are less symmetrical, more elevated at the 
edge, aud the scales with which they are covered, fewer, smaller, and 
dirty-whitish, rather than lustrous in color. In syphilis, the erup- 
tion is less geueralized, and shares with the other syphilodermata 
the brownish aud purplish hues of the skin beneath, lacking the 
vivid redness and pinkish-red of many non-syphilitic lesions. The 
scales of many of the syphilides which resemble psoriasis partake of 
the character of crusts, being agglutinated by pathological exudations 
from the patch ; they are rarely so exclusively squamous as in 
psoriasis. In syphilis, the tendency of the patch is to exhibit an 
affected surface somewhat beyond the line of the scales ; in psoriasis, 
the scales more frequently reach beyond the border of the affected 
epidermis beneath. The squamous syphiloderm of the palms and 
soles often occurs in these localities only. Psoriasis is extremely 
rare in such situations, and is almost never limited to that region 
exclusively. A psoriasiform circlet limited to the region of the 
mouth, nose, or chin, will generally prove to be syphilitic. The 
disease which has for a long time persisted in the production of 
squamous patches can generally be demonstrated to be psoriasis, as 
syphilis changes its type in the course of months. 

Tinea Circinata. — Here the discovery of the parasite, a his- 
tory of contagion, and the frequent limitation of the disease to a 
single patch (a feature exceedingly rare in psoriasis), will usually 
suffice to establish a diagnosis. In ringworm of the body the scales 
are bran-like, and more abundantly formed at the margin of the 
patch where the fungus is luxuriant ; while in psoriasis, the scaliness 
is usually equally pronounced over the entire area of an invaded 
patch, unless the disease is in process of involution. The occasional 
occurrence of vesicles and vesico -papules at the peripheral border of 
the patch in ringworm is never observed in psoriasis. Ringworm 
is never generalized symmetrically ; and upon the scalp or beard the 
discovery of brittle and broken off hairs should always suggest 
examination for the parasite. 

Treatment. — The treatment for the relief of the disease must nec- 
essarily be limited to the removal of its objective features. This 
treatment may be internal, with a view to the indirect action upon 
the skin, of the drug selected ; or topical, with a view merely to the 
reproduction of a sound epidermis in the patches of disease. 

Arsenic enjoys the highest rank in the internal treatment of 
psoriasis. What it is capable of accomplishing in other cases it can 
with best effect accomplish here. Whatever failures must be charged 
to its account in the attempt to relieve other cutaneous eruptions, 
cannot safely be ignored here. 

The facts are these: arsenic administered internally is assuredly 
capable of relieving a certain proportion of cases of psorasis. Given 



psoriasis. 267 

improperly in any case, it may be either powerless or manifestly in- 
jurious. In a certain proportion of patients, most carefully selected 
as fit subjects for its therapeutic action, arsenic will prove utterly 
valueless in the most skilled hands. It cannot be demonstrated to 
possess the power to prevent recurrences of the disease, and yet the 
latter must be recognized as one exceedingly liable to recur. Un- 
fortunately, the proportion of cases in which it will and in which it 
will not, exhibit its happiest effects, is not known. 

The following rules for its administration are to be in general 
observed. It should be given with or immediately after the inges- 
tion of food, so that it may be commingled with edible substances in 
the stomach. It should be given at first in small doses, which are 
to be cautiously increased. The possibility of the production of 
toxic effects should be remembered, and on the appearance of these 
the remedy is to be given in a smaller dose, and not completely dis- 
continued unless such a course be imperative. If its administration 
be once determined upon, the arsenic should not be hastily with- 
drawn and another remedy substituted for it, but persistence for 
months should be enforced if no serious objection exist, lest the time 
be w r asted which has been already expended in the effort to relieve 
the disease. 

Arsenic is unsuited for all cases of psoriasis occurring with rather 
acute symptoms, such as subjective sensations and unusually vivid 
redness of the patches. It should not be given when the disease is 
in process of evolution, and, therefore, not in psoriasis punctata and 
guttata, unless the lesions have been long limited to patches of the 
sizes to which these names are given. For the same reasons it is 
often objectionable in the psoriasis of the young, for, though the 
drug is usually rather well tolerated in such periods of life, it is, un- 
fortunately, in these also where the disease is most often encountered 
in its progressive stages. 

The remedial effect of arsenic, when such is obtained, seems to 
depend upon the impression it exerts upon the rete, and that part of 
it especially which lies in connection with the derma. When the 
metal is injected subcutaueously, its first effects, accordiug to Jamie- 
son and Xunn, 1 are indicated by the appearance of a faint narrow 
band along the base of the columnar epithelia immediately next the 
corium. This is due to a softening of the protoplasm which sepa- 
rates the epidermal from the dermal elements. Subsequently, the 
remoter epithelia are involved, the protoplasmic threads becoming 
obscure, the characteristic arrangement of the epithelia less evident, 
and the natural features of the rete distorted, so that it remains 
attached to the derma by tags and the prolongations which it sends 
down to the cutaneous glands. Jamieson suggests that arsenic stim- 
ulates the epithelia to exhaustion, that layer which lies next the 
bloodvessels containing the metal first appreciating its effects. 

1 See the paper by the Iforrner on the Histology of Psoriasis, E linburgh Medical Journal 
January, 1879, p. 627. 



268 DISEASES OF THE SKIN. 

The preparation usually employed is Fowler's solution, whose ex- 
hibition should always be begun in doses from half a minim (0.033) 
to three minims (0.20) ; this amount to be contained in a solution of 
fixed and relatively large dose, such as a teaspoonful of the infusion 
of peppermint ; the wine of iron ; dilute syrup of gentian or of 
orauge blossoms ; or the compound tincture of cardamom with 
water. When only remedial effects are obtained, such as diminu- 
tion of the scaliness, the dose may be steadily continued without 
change for long periods of time, and usually with advantage for 
some time after the symptoms of the disease have entirely disap- 
peared. When, without the production of toxic effects, the eruption 
seems quite unaffected by the treatment, the arsenic may be, very 
carefully and always under the direction of the physician only, 
pushed till twenty and even thirty drops of Fowler's solution [the 
latter equivalent to one-third of a grain (0.022) of arsenic] are 
administered at a dose. 

The constitution of the Asiatic pill has been given in the chapter 
on general therapeutics. The pill is less likely to be as well toler- 
ated by the stomach as Fowler's solution, but cases are on record in 
which the psoriasis which proved rebellious under the administration 
of the liquor arsenicalis, Donovan's solution, and other internal 
remedies, yielded to the influence of arsenious acid in pilular form, 
Hebra has given two thousand Asiatic pills to a single patient 
before the disease disappeared ; and in no instance has he seen any 
ill effects produced. 

With regard to the vulgar opinion respecting the arsenic habit 
which a long familiarity with this dosage has been supposed to beget r 
the author considers it a curious circumstance that he has never yet 
encountered such an instance in a psoriasic subject who was consum- 
ing arsenic. Patients who for several consecutive years have, with- 
out interruption, pursued an arsenical course, thus barely succeeding 
in keeping their cutaneous ailment out of sight, will in many cases 
affirm that, apart from any trifling and accidental toxic symptoms, 
and those evident in the course of the eruption, they would not be 
sensible of the fact that they had taken the drug. 

With an enlarging experience, one views with greater distrust 
each year the benefits to be derived from arsenic in any untried case 
of psoriasis. The great possibilities of its failure, of the repeated 
recurrence of the eruption, of the necessity of continuing the medi- 
cation for one or two years, and, after that period of time, of 
witnessing a generalized development of the disease to an extent 
quite equal to that exhibited at the outset — all these considerations 
should certainly have some weight in the mind of an ordi- 
narily prudent man. Is the ultimate result in such cases worth the 
cost by which it is obtained ? In such cases certainly it would seem 
not. In the others, where, under a judiciously directed arsenical 
course, the eruption slowly disappears and fails to recur, the value 
of the treatment is incontestable. As before stated, the proportion 
in which these two classes of cases are related, is not known. The 



psoriasis. 269 

patients in the last-named category, in all probability, decidedly out- 
number the others. 

The course which, under the circumstances, seems preferable, is 
this : Instead of resorting first to the arsenical dose and afterward 
to other measures, the order should be reversed. That psoriasis 
which fails to respond to other treatment may be finally subjected 
to the influence of arsenic. He who, having vainly tried other 
approved measures, essays at last the virtues of this medicament, 
ought certainly to exhibit no impatience while testing his case with 
it. He should be willing to try it fully and fairly, and be of all 
men least ready to exchange it for a less valuable substitute. No 
reference is here made to the effect of conjoined internal medication 
with arsenic and external treatment by topical applications. How- 
ever desirable it may be, in the management of any individual case, 
to arrive at the desired end by the speediest method, it is evidently 
needful, in order to assign to arsenic its exact therapeutical value, to 
understand what it can accomplish unaided by topical measures. 

Crocker has lately advised the use of turpentine in ten minim 
doses properly emulsified, after meals, the dose being increased to 
three times that first given, an abundance of barley-water being 
drunk during the period of its administration. Haslund recom- 
mends the iodide of potassium, increased from the smaller to the 
largest tolerated doses. As many as six hundred grains have been 
administered in this method per diem. It is of occasional service. 
The wine of antimony in five to ten minim doses ; chrysarobin, one- 
sixth of a grain, rubbed up with sugar of milk three times daily ; 
bromide of potassium and the iodide of sodium, have also been ad- 
ministered in some cases with reported success. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remem- 
bering that arsenic is superior to them all. If arsenic fails so fre- 
quently, what remains to be said of the other articles on the list? 
Phosphorus, tar, copaiba, cantharides, colchicum, and pilocarpine, 
have at times a feeble or transitory influence over the patches of the 
eruption, but their employment will disappoint far more often than 
satisfy. Iron, quinine, cod-liver oil, and the salts of the alkalies, 
will fill important indications in the treatment of certain classes of 
patients, but these are in the minority, as the eruption is often seen 
in perfectly vigorous and otherwise healthy subjects. 

After the use of any one of these remedies, it is rare to recognize 
any decided effect upon the cutaneous symptoms, even when patients 
in whose case they were indicated, improve under their use. 

The same in general may be said of the use of dietary articles in 
psoriasis. As no ingesta save the substances already named are re- 
cognized as influencing the eruption to any perceptible degree, the 
diet suitable for a patient may be in brief described as that which is 
both wholesome and nutritious. 

Most authors agree upon the value of a greatly restricted diet. 
Acids, alcohol, and fatty substancess should be excluded. Meat 



270 DISEASES OF THE SKIN. 

should be sparingly supplied ; cooked vegetables and fruits may be 
freely eaten. Coffee, tea, and tobacco should in general be interdicted. 

Passavant, of Frankfort, on the other hand, claims to have cured 
himself and others by an exclusive diet of meat. 

The arseniate of sodium in pill form and arseniate of iron have been 
recommended by Biell. Lipp has injected arsenious acid subcuta- 
neously. Robinson advises the liquor potassse, the citrate or acetate 
of potassium, or the bicarbonate of sodium in plethoric and rheumatic 
patients. In the gouty state with excess of urates in the urine, he 
advises : 



J& . Potass, acetat. ^ j ; 32 

Spts. sether. nit. f.^ss; 16 

Vin. colchici f .^ i j ; 8 

Syr. aurantii f^jss; 48 

Sig. A dessertspoonful three times daily in water after meals. 



M. 



The influence of climate in inveterate psoriasis should never be 
ignored. It has been already stated that many patients who suffer 
from repeated relapses of the disease are worse in winter, and either 
better or entirely free from the eruption in summer. For the same 
reason, in a mild climate, where the temperature is uniformly regis- 
tered at or near a point of maximum comfort for the skin, the disease 
will be both infrequent and less severe. 

McCall Anderson believes that sea-air and sea-water are generally 
prejudicial to psoriasic patients, but the statement is disproved in the 
cases of hundreds who have removed from an interior climate to the 
sea-shore, solely with a view to the benefit to be thus received. 

The external, or local, treatment of psoriasis requires patience, care, 
and a certain degree of skill. Properly conducted, its results are 
reasonably satisfactory in a large majority of cases. 

The first indication to be met is the complete removal of the 
epidermic scales from the patches, and this is accomplished in various 
ways. It is preferable to secure first their maceration in some fatty 
substance, such as one of the oils, or glycerin, or vaseline, after 
which they may be washed off by the aid of soap and water, in a 
general bath if the eruption be extensive. If it be localized, these 
oily or fatty substances may be spread upon pieces of lint or cotton, 
and thus retained by a bandage in contact with the skin. The scales 
may also be speedily removed with the dermal curette, if they occur 
in few patches, or if the latter are to be found in totality or part 
upon some portion of the body where the disfigurement demands 
special attention, as upon the forehead and cheeks. The squamous 
masses are also removable by water alone, as after maceration of the 
skin in a bath, or after a profuse diaphoresis, or even moderate 
exudation of sweat, if evaporation of the latter be prevented by 
covering the affected part with oiled silk or rubber cloth. Usually 
there is no difficulty in removing these scales, patients often declaring 
to their physicians that they can themselves cleanse the surface, if 
they can be shown how to prevent the recurrence of the desquamation. 

Baths play an important part in the subsequent treatment of the 



PSORIASIS. 271 

disease. They may be employed, as by Hebra, so that the patient 
remains in the water for from four to eight hours in the day ; or be 
medicated by the addition of sulphur, tar, or other substances, so as 
to combine a medicative with a macerative effect. In private prac- 
tice, these baths are much less available than in hospitals. When 
the eruption is generalized and an excessive macerative effect is 
desired, rubber clothing answers a better purpose. In such cases 
an undershirt and drawers may be worn, made of soft rubber cloth, 
of the size of the undergarments usually worn by the patient, the 
latter wearing these for several hours of the day. The sweating is 
often profuse and debilitating to such an extent that the psoriasic 
skin will rarely tolerate the treatment for an entire day, or for even 
that part of it in which active labor is performed. By this means 
alone, it will at times be found possible to secure complete disap- 
pearance of the patches. 

In other more obstinate cases, or in those where for any reason 
such treatment is indicated, as upon the scalp and face, sapo viridis 
may be employed with advantage in the soap and water treatment. 
The spiritus saponis kalinus [two ounces (60.) of the soap to one 
(30.) of alcohol] may be briskly rubbed over the patches by the 
aid of a piece of flannel or sponge, and then immediately washed off 
with the oil and scales in a surplus of hot water, or be left for a time 
in contact with the part. Hebra and Kaposi made use of a species 
of soap paste, made by rubbing into each patch a small quantity of 
the green soap to which a little water is added till the proper con- 
sistency is obtained. These inunctions are repeated twice daily for 
six days. The epidermis becomes then brownish-colored, and in 
three or four days afterward exfoliates in lamellae. Then a general 
bath cleanses the surface. In the French hospitals a somewhat 
speedier method is pursued. On the evening of the first day, the 
patient is anointed with the green soap which he retains upon the 
skin during the night. In the morning he takes an alkaline bath, and 
immediately after is thoroughly anointed with lard. This is repeated 
on the second and third days, after which the patient is usually 
ready for any topical medication of the diseased parts. 

For the yet more obstinate cases in which the exfoliation of the 
epidermis is not readily induced, still more energetic measures have 
been adopted, such as the local use of salicylic acid in alcohol, one 
drachm (4.) to four ounces (128.), caustic acid and alkalies, scrub- 
bing the patches with nail-brushes, floor-brushes, etc., and the use of 
clean, white sand. 

Once ready for topical medication, the patches may first be sub- 
jected to the local action of tar, a remedy which has enjoyed the 
highest reputation for the relief of the disease. It will, however, 
accomplish the result desired, only when applied so that it is well 
tolerated by the skin. In very young patients, as also in those 
whose skins are tender and irritable, or who are suffering from any 
of the acute phases of the disease, it may prove decidedly injurious 
by aggravating the latter. The rule should be, always to employ it 



272 DISEASES OF THE SKIN. 

at first tentatively over a relatively small portion of the surface, 
upon which the medicament should remain for several hours, as tar 
will not in all cases promptly produce its injurious effects. These 
are, subjectively, a sense of heat and pain ; and, objectively, heat to 
the touch, redness, and tumefaction of the part. Often black puncta 
are visible when the tar is lodged in the orifices of the cutaneous 
follicles, simulating thus, the " black head " of the comedo, a con- 
dition termed by Hebra, " tar-acne." 

Pix liquida, the oil of cade, or preferably the oleum rusci may be 
employed, in the form of a salve, a drachm (4.) of either to the 
ounce (32.) of lard or other fatty basis (lanoline, vaseline, etc.). 
A thin stratum of such ointment may be, several times in the day 
or merely at night, painted over, or well rubbed into a patch denuded 
of scales. In Vienna, a still more energetic effect is secured by 
using soft soap freely over the patches while the patient is in the 
bath, then anointing him with tar, and finally returning him to the 
bath where he remains for from four to six hours. For localized 
eruptions, green soap in combination with tar and alcohol, serves an 
exceedingly useful purpose, either in the proportion of equal parts 
of the three ingredients, or by combining them in other proportions, 
as, for example : 



Sig. 



Saponis viridis 


. liv; 


130 


01. rusci \ 
Glycerin. J 


aa 3j; 


30 


01. rosmarin. 


3>s ; 

Oss; 


7 


Spts. vin. rectif. 


500 


For external use. 







M. 



Other combinations of service are Bulkley's " liquor picis alka- 
linus," the formula for which is given in the chapter on eczema ; and 
Wilkinson's salve, as modified by Hebra, the latter combining the 
remedial effects of sulphur, tar, and soap, as follows : 

R. Sulphur sublimat. 1 .^ Jg lfi 

Oi. rusci [crud vel recti!. J J ° 



S^xis viridis | aa 3 j ; 30 

Cret. preeparat. ^ ij ss ; 3 

Sig. Wilkinson's salve, modified. 



M. 



Where the sensitiveness of the skin to the action of the tar has 
not been tested, or when the skin is particularly tender, a small 
quantity of the Wilkinson salve may be added to any simple oint- 
ment, or Spender's ointment of tar (see the chapter on General 
Therapeutics) may be substituted for it ; afterward a drachm (4.) 
of the oil of tar, or oleum rusci, to the ounce (82.) of oil of almonds 
or of alcohol, may be employed. 

When toleration is established, the tar may be rubbed over the 
patches in a pure state with a stiff brush, a procedure preferred in 
some parts of Germany, after which the patient either remains for 
some hours in bed, or is powdered with soapstone and bandaged with 
flannel, so that when the clothing is replaced it may not adhere to 



psoriasis. 273 

the tar. Naphthalin, ichthyol, and carbolic acid operate in psoriasis 
in the same way as the tars, but are decidedly inferior to it. 

Absorption of any tarry compound applied externally may result 
in general toxic symptoms, including fever, vomiting, diarrhoea, 
strangury, and elimination of the toxic agent in secretions which are 
blackened by its presence. These symptoms are usually relieved in 
from twenty-four to forty-eight hours after the discontinuance of the 
drug. 

Kaposi 1 was first to employ beta-naphthol, the formula of which 
is C 10 H 8 O in psoriasis (as also in eczema). It may be applied in 
alcoholic solution. Under the employment of a fifteen per cent, 
ointment, the author reported speedy disappearance of psoriasic 
patches. It did not stain the skin, hair, or nails. 

JBalmanno Squire, 2 however, reports that the naphthol was, in cer- 
tain experiments conducted by himself, without appreciable effect 
when used in the strength of from ten to twelve per cent., and that, 
when he increased the quantity of the agent till the ointment was 
applied in the strength of twenty-five and even fifty per cent., there 
was the production of merely irritative effects. 

By many practitioners, chrysarobin (or chrysophanic acid) is placed 
above all the tars in the local management of psoriasis. It is a 
crystalline powder of the color of old gold, insoluble in water, but 
readily dissolved in hot alcohol, acetic acid, benzol, vaseline, and hot 
fat. It is derived from the " Goa powder " of the East Indies, or 
the " araroba powder" of Brazil, araroba em po, 3 whose employment 
in psoriasis was first recommended by Mr. B. Squire, of London, 
Eng., in 1878. 

The drug is best applied in the form of an ointment, varying in 
strength from half a scruple (0.666) to a scruple (1.333) to the ounce 
(32.) of vaseline or cerate. It is occasionally used in less and greater 
strength, but, with pure specimens, it is liable in larger proportions 
to produce disagreeable effects. These are declared in a hot, itching, 
swollen, irritable, and erythematous skin, stretching from the surface 
of application, with tolerable uniformity, in every direction. It is, 
even in the strength named above, necessary to begin its use with 
caution, testing it by application first to a limited area of integument. 
These excessive effects usually subside in a few days. An ignorant 
woman to whom a chrysarobin ointment was given in 1879, with 
directions to test it carefully at first by application over the elbows 
of her daughter, stripped the latter before an open fire, and rubbed 
the ointment over the entire surface for the space of half an hour. 
The result was an intense erythema lasting for six days with con- 
siderable distress, and the complete disappearance of the psoriasis 
which did not fail to reappear in eight months. 

When the drug produces its most brilliant effects, the psoriasic 
patch, previously denuded of its scales, assumes a whitish and nor- 

1 Wien. med. Wochenschr., May 28, June 4 and 11, 1881. 

2 Brit. Med. Journ., Jan. 14, 1882. 

3 This article was obtained from Messrs. Silva, Limaos <& Co.. of Bahia, Brazil. 

18 



274 DISEASES OF THE SKIN. 

mal aspect, contrasting thus somewhat remarkably with the chocolate 
to brownish-black discoloration of the stained skin at the periphery. 
This coloration, when produced either by the ointment directly or by 
a frequent transfer of its ingredients to other parts by the medium 
of the clothing and hands, involves also the nails, hairs, and under- 
linen of the psoriasic patient. Its employment upon the face and 
scalp is thus largely interdicted. The staining of the skin and its 
appendages disappears entirely in time, but always slowly. 

An improved plan of using chrysarobin externally has been sug- 
gested by Fox, of New York. 1 

A soit paste is made by rubbing the chrysarobin with a sufficient 
quantity of water, and smeared upon the psoriasic patches, the scales 
of which have been previously removed by one or more hot baths, 
with soap friction. As soon as the paste has dried, which it does in 
one or two minutes, a layer of collodion should be allowed to flow 
over each patch, and to harden into a protective coating. This will 
remain in place for several days, or longer, according to the location 
of the patches ; and when it falls or is washed off, the application of 
the powder and the collodion should be repeated. By this procedure, 
the chrysarobin in full strength is kept in contact with the affected 
skin, and prevented from exciting undue inflammation of surround- 
ing parts, or staining the clothing. A mixture of the powder and 
the collodion may be used, but it is less efficacious. A film of collo- 
dion doubtless interferes with the action of the acid upon the skin. A 
somewhat similar plan consists in the use of gutta-percha tissue to 
retain a strong chrysarobin ointment in contact with psoriasic patches. 
The edges of this tissue will adhere tightly to the skin if a small 
camePs-hair brush, dipped in chloroform, be passed rapidly beneath 
them. 

More recently, following Auspitz's plan, this same author has 
combined these articles in a convenient form, by adding ten parts of 
chrysarobin and ten of salicylic acid to fifteen of sulphuric ether 
and one hundred of flexile collodion. This rapidly dries over the 
psoriasic patch, where its specific effects are produced. 

Pyrogallic acid, first suggested as a remedy for psoriasis by Jarisch, 
is inferior to chrysarobin. The fact that several deaths have now 
been reported as consequent upon its use, deters many from making 
trial of it in a painless and merely disfiguring disease. It is used in 
a ten per cent, vaseline ointment ; is effective, though less rapid in its 
effect than chrysarobin ; is cheaper ; is odorless and painless ; and 
discolors to a less extent the sound skin. Both remedies are capable 
of being absorbed from the surface, and of producing constitutional 
symptoms, pyrexia, strangury, and blackish evacuations. But in the 
case of pyrogallic acid only, so far as is known, have these symptoms 
resulted fatally. 

Crocker, of London, similarly uses thymol in ointment, half a 
scruple to half a drachm (0.666-2.) to the ounce (32.) ; and Wil- 

i The Medical News, March 18, 1882, p. 289. 



psoriasis. 275 

Hamson advises turpentine two drachms (8.) to the ounce (32.) of 
olive oil, with the odor corrected by the oil of lemon. Charteris 
treated thus a single limb of a psoriasic patient ; which was subse- 
quently wrapped in wool, with the curious result of relieving the 
psoriasis of the other limb, possibly in consequence of the absorption 
of the remedy. The danger of strangury in such cases must not be 
overlooked. 

The nitrate, as well as the iodides and oxides, of mercury is applied 
by many practitioners in the form of ointment to patches of psori- 
asis, usually few in number and limited in extent. The action of 
these agents is, however, inferior to those already named, and the 
range of their availability being quite limited, they should be es- 
teemed lightly in the local treatment of the disease. 

The local treatment of psoriasis of the scalp and face by many of 
the articles named above is often forbidden by reason of their dis- 
agreeable odor, or too energetic action, or by the staining which they 
produce. 

There is no better substitute for them all in these regions than the 
ammonio-chloride of mercury in ointment, from ten to thirty grains 
(0.66-2.) to the ounce (32.). In the same way, the tincture of ben- 
zoin may be employed, half a drachm (2.) to the ounce (32.) of salve. 

Salicylic acid is capable alone of securing relief in many cases. 
There are few better methods of its application than by making use 
of the Lassar paste, two parts each of the zinc oxide and finely 
powdered starch rubbed together with four parts of vaseline. To 
this may be added the acid in desired proportion. With from five to 
ten grains (0.333-0.666) a minimun of effect is producible. In the 
strength of from twenty grains to twice that amount, the stratum 
corneutn is usually reduced over the part on which the paste is ap- 
plied, to a whitish pulp which may be scraped away with a curette 
without difficulty. Other articles, more recently vaunted in the 
external treatment of psoriasis, are : thilanine, which seems really to 
possess some value ; hydracetine ; rufigallic acid, ten per cent, in 
unguent form ; the cupric oleate ; anthrarobin ; and gallacetophenone 
five to ten per cent, in salve or traumaticine. 

When practicable, the skin affected with psoriasis should be always 
exposed in a sufficiently warmed apartment to the direct action of 
sunlight. By this measure alone, it is often relieved of its eruption. 

Prognosis. — The permanent relief of psoriasis is not insured by 
any treatment of a grave case, though hundreds of cases are perma- 
nently relieved by even the simplest treatment. The disease often 
recurs, and may do so repeatedly for the greater part of a life. Per- 
manent relief, therefore, should never be either predicted or promised 
in any case. Once relieved, it should be the aim of the practitioner 
to guard against all possible recurrences. After relief of any obsti- 
nate or recurrent attack, as also in all inveterate cases, the prognosis 
is greatly improved by removal to a climate suitable for the psoriasic 
patient. 



276 DISEASES OF THE SKIN. 

Pityriasis Maculata et Oircinata. 

(Pityriasis Rosea ; Herpes Tonsurans Macnlosus ; Pityriasis 

Circinata.) 

Pityriasis Maculata et Circinata- is a mild febrile disorder of specific character 
and determinate course, in which appears a cutaneous exanthem. in the form 
of multiple, circumscribed, superficial, roundish or oval-shaped, yellowish and 
reddish patches, covered with fine scales, and seated for the most part on the 
trunk. 

This disorder has been recognized and carefully described by 
Gibert, Bazin, Horand, and Duhring. It is non-contagious and 
benign in its course, lasting from a few weeks to three months. 

Symptoms. — The subjects are children, or more commonly young 
adults, but the author has seen it in middle life in both sexes. The 
outbreak of the disease may be preceded for a variable time by 
languor, lassitude, iDappetence, or a feeling of chilliness. Occasion- 
ally the first noticeable symptom is the occurrence of mild fever, the 
temperature rarely rising above 102° F. 

The eruption often escapes recognition for a time after its appear- 
ance on account of its sparseness or the trifling degree of pruritus it 
arouses. When fully developed, it is characterized by the conspicuous 
appearance over large surfaces of the trunk, especially the integu- 
ment covering the clavicles, ribs, and scapulse, of numerous pin-head 
to small coin-sized, circumscribed, roundish or oval-shaped, slightly 
elevated, macular or maculo-papular lesions. These may be discrete, 
closely set together, or confluent, and instead of being elevated may 
be either on a level with the general surface, or even slightly de- 
pressed, with an annular border. They are dry, covered with fur- 
furaceous scales, and vary in color from a yellow or tawny shade to 
a deep red. The infiltration is slight, and the patch is superficially 
situated. 

The oval contour is that more often recognized as characteristic of 
a well-developed lesion, its long axis usually at right angles to the 
vertical axis of the body, and the terminal extremities of the oval 
slightly frayed by the irregularity with which the fine branny scales 
are here disposed. The tawny, salmon-shaded hue of such patches 
is then highly characteristic of the disease, the patch slightly enlarging 
by peripheral extension, and leaving a relatively clear centre. The 
scales have often a silvery-grayish hue. The eruption may be toler- 
ably well generalized, but the face and other exposed parts of the 
body usually escape, though the scalp may be involved. In the 
latter event the hairs are unaffected. 

The variations exhibited by the exanthem in this affection are dis- 
tinct, but scarcely ever sufficient to mask the characteristic appearance 
of the oval or circular plaques over the neck, arms, abdomen, or ex- 
tremities, sometimes first appearing over the latter and extending 
thence to the trunk. At times a retiform expression is given to the 
picture by coalescence of the patches. There may be moderate itch- 



DERMATITIS EXFOLIATIVA. 277 

ing with nocturnal exacerbation, but the type of the disease is always 
mild. 

Vidal has described a disorder, uuder the title Circixate and 
Marglnate Pityriasis (pityriasis circine* et margine), which he 
regards as due to the microsporon anoruceon, or dispar. It also is 
characterized by slightly scaling rosy patches, appearing over the 
trunk and extremities. It represents, however, a disorder in which 
the borders of the patches are somewhat elevated ; suggesting the 
marginate form of eczema described by Hebra. The disorder may 
persist for mouths. 

Etiology and Pathology. — The causes of this disease are obscure. 
According to Bazin, it occurs in lymphatic and scrofulous patients 
chiefly. 

The most of the cases coming under the author's observation were 
of patients having light hair and delicate skins, who had been 
enfeebled by great physical fatigue or overtaxation in school. Pro- 
fuse perspiration has been assigned as a cause by Horand. 

Diagnosis. — The disease is to be differentiated from ringworm of 
the body by the absence of vesicles, the tendency to symmetry of dis- 
tribution of the lesions, their multiplicity, the characteristic yellowish 
centre of the oval rather than circular patch, and the constitutional 
symptoms. Psoriasis differs greatly in the color, quantity, and char- 
acter of the scales present, and in the contour of the patch. In the 
scaling syphilodermata, the region of the body involved, the presence 
of plantar and palmar lesions, the constitutional symptoms and history, 
and the color of the patch, which is usually of a deeper and dirtier 
red than in the disease under consideration, will point to the diagnosis. 
In the macular syphiloderm (" syphilitic roseola ") the closer prox- 
imity of the lesions will point at once to the difference, since the 
patches of pityriasis maculata et circinata are, as a rule, far more 
widely separated. The greasiness of seborrhceic scales and the pallid 
hue of the integument beneath, when the former are removed, differ 
from the congested skin beneath the dry scale in the form of pityriasis. 

The Treatment is expectant. Quinine, the sodic salicylate, and, 
later, the ferruginous tonics are indicated in most cases. Locally, 
tepid bathing in the alkaline or bran bath is usually found grateful. 
This is to be followed by the application of a dusting powder. 

Dermatitis Exfoliativa. 

Exfoliative Dermatitis is a more or less generalized cutaneous disorder in 
which, either in circumscribed patches or over the entire surface of the 
body, the skin is reddened and covered with scales which are freely exfoliated 
from the surface. The disease may be accompanied by febrile and other 
general signs of systemic disturbance. 

Some confusion, both as to the names of diseases and as to the dis- 
eases themselves, has existed in connection with the subject of all 
generalized exfoliative cutaneous disorders. More investigation is 



278 DISEASES OF THE SKIN. 

needed before definite limits can be established for several of the 
disorders to which authors refer under these titles. By some, the 
term dermatitis exfoliativa is held to be synonymous with pityriasis 
rubra, the disease next to be considered. In these pages, pityriasis 
rubra is, for the present at least, distinguished as a distinct disease, 
and dermatitis exfoliativa is made to include the exfoliative and exu- 
dative disorders of the skin not properly considered in any other 
connection. 

Classing these latter together, as for the most part of acute type, and 
distinguishing them from the chronic form of dermatitis exfoliativa 
represented by pityriasis rubra, it may be said of them all that they 
often present features of wide diversity. At one time the exfolia- 
tive dermatitis begins and ends in a single patient as a well-defined, 
distinct, and specific disease of mild symptoms, definite career, and 
benign type. In another case it occurs as a sudden or gradual 
change in a pre-existing disorder, such as an eczema or a psoriasis 
(Gamberini). Again, beginning in one or another of the simpler 
forms described above, it may become chronic, and, in its symptoms 
and course, be indistinguishable from a pityriasis rubra. 

It may be ushered in with mild febrile symptoms, which may have 
been preceded or not by malaise, languor, or a variable period in 
which the general health has been impaired. Often, however, all 
prodromata are absent. 

The eruptive symptoms are a more or less shining and viv'd red- 
ness of the skin in one or several plaques which become in the course 
of a week the seat of numerous fine bran-like scales. Any region of 
the body may be affected, though the articular folds of the skin, 
genital region, head, and trunk, are often the seat of the disease, 
which may involve consecutively one part after another till, in a week 
or a fortnight, the whole surface is invaded. It may be limited to 
one region, or, yet again, several distinct regions may be simultane- 
ously involved, as the head and lower limbs, or the thorax and 
external genitals. The hands and feet are usually the last to be 
invaded. The eruption may appear in reddish patches of well- 
defined or very indeterminate outline. The skin affected may be 
slightly, or apparently not at all, infiltrated and raised. The itching 
may be slight or severe. The redness displayed in the skin which 
is the seat of the scaling, may be of the brightest crimson, " erysipe- 
latous," violaceous, or purplish shade, or with a faint suggestion of 
yellowness. The scales are usually formed in the greatest abundance 
and are commonly seen loosely covering the reddish integument upon 
which they rest, though they are also shed in the greatest profusion 
when the surface is lightly swept with the hand. They are always 
whitish, minute, and bran-like, never in the so-called pastry-crust 
condition of the scales in pemphigus foliaceus. 

In well-marked cases the features may be slightly disfigured by 
tumefaction of the lips, swelling of the ears, and puffiness of the lids. 
In all cases, the skin is dry and never moistened by a pathological 
discharge. The scales shed in such abundance are always white, 



DERMATITIS EXFOLIATIVA. 279 

imbricated, and silvery in hue. They are usually larger and coarser 
upon the lower limbs than over the neck, face, or chest. 

In the course of the disorder, the hairs may fall ; and, in some 
cases, the resulting alopecia is general. When the nails also are lost, 
there is rarely any special pre-existing onychia to be noted. The 
mucous surfaces of the eyes, nose, mouth, and throat may participate 
in the general disorder and become the seat of inflammatory and, in 
rare cases, even pseudo-membranous and exulcerative processes. 

The itching may be entirely absent ; when present and in severity, 
it is relieved even before the complete restoration of the integrity of 
the skin. It is apt to recur with each relapse, at which time also the 
fever is usually relighted. 

In most cases the disease is terminated in the course of two or 
three months, after which convalescence from the emaciation and 
possible complications (furunculosis, abscesses, etc.), may require an 
equal length of time. Pigmentation is always left for some time 
after the restoration of the health of the skin. 

Pathology. — Brocq 1 has made a specially careful study of this dis- 
order, and his results are more or less confirmed by Vidal and 
Baxter. These observers recognized an infiltration of the papillary 
layer of the corium with embryonic cells, dilatation of the papillary 
and sub-papillary vessels, disappearance of the stratum granulosum 
and stratum lucidum of the epidermis, and appearance of nuclei in 
the cells of the stratum corneum. According to Quinquaud, 2 a 
diffiuse myelitis and parenchymatous neuritis of cutaneous nerves 
may be responsible for all these changes. 

Etiology. — According to Brocq, the disease affects patients who 
have not previously suffered from any cutaneous malady. The dis- 
order is rare ; and is said to occur more often in adult male subjects. 

Diagnosis. — The disease is to be distinguished from pityriasis 
rubra by the variety of its symptoms and course : from pemphigus 
foliaceus by the absence of bullae and grave systemic trouble ; and 
from scarlet fever, by the absence of sore throat and its much more 
tardy evolution. Though, in general, a disease having a cyclical 
career and special characteristics, it may at times be lighted into 
activity by a diffuse psoriasis of acute type, or a squamous eczema 
becoming generalized. In such cases the diagnosis is qualified by 
the pre existing disorder. 

Treatment. — The disease is unquestionably most relieved by any 
article which induces profuse sweating ; and, hence, both jaborandi 
and pilocarpine have been employed in it with even brilliant success. 
Quinine, the sodic salicylate, aucl the mineral acids are often indi- 
cated. The strength of the sufferer is always to be supported by 
appropriate measures. Hebra's diachylon ointment, one part to four 
of vaseline, with from five to ten grains (0.33-0.66) of salicylic acid 
to the ouuce (32.) of the whole, is usually most grateful to the skin. 
One of the combinations of lime-water, olive oil, and the oxide of 

1 Arch. gen. de Med., 1884. 2 Bulletin de la Societe Anatom., 1879. 



280 DISEASES OF THE SKIN. 

zinc, described in the treatment of eczema, may, however, be well 
employed as a substitute for it. 

Prognosis. — The disorder may prove fatal in exceptional cases. 
Generally, however, recovery may be expected. Often convalescence 
is tedious, protracted, and complicated by the occurrence of furuncles 
and cutaneous abscesses. 

Dermatitis Exfoliativa Infantum. — Under this title v. 
Rittershain 1 and others have described an exfoliating non-contagious 
disease of the skin in infants from six days to five weeks old, the 
disorder running from seven to ten days. It is developed as an 
erythema with dryness of the skin, from which branny scales are 
exfoliated, leaving a peculiarly dry, reddish, and fissured integument 
beneath. The angles of the mouth and mucous outlets generally are 
specially involved. Often buccal lesions are present. The face and 
limbs are the seat of the chief features of the disease. It lasts for 
about one week and is unaccompanied by fever. The malady occurs 
more often in boys than in girls. In severe cases crusts form where 
the rhagades exist, and there is considerable pain and constitutional 
disturbance. Occasionally the skin is attacked by furunculosis after 
the disease has existed for a week. Relapses are common and recov- 
eries occur in most cases. The treatment is by soothing applications 
to the cutaneous surface. 



Pityriasis Rubra. 

Gr., 7virvpa } bran. 

(Dermatitis Exfoliativa. Fr., Pityriasis rubra aigu.) 

Statistical frequency in America : 0.032. 

Pityriasis Bubra is a rare, chronic, and usually grave inflammatory cutaneous 
disease ; as a rule, involving the entire surface of the body, in which the skin 
is deeply reddened and exfoliates lamellae of scales in large quantities. 

Symptoms. — This disease is characterized throughout its course by 
a superficial hyperemia and inflammation of the skin, declared in 
patches or by a diffuse redness of a vivid or lurid tint, and an abun- 
dance of small or large, lamellated, bran-like scales, which are con- 
tinuously exfoliated from the epidermis throughout the course of the 
malady. Patients rarely present themselves for observation till a 
considerable portion of the surface is involved ; but Kaposi states 
that in two cases observed by him the disease was first noticed in the 
neighborhood of the articulations. There are never at any time other 
lesions of the skin, betrayed in vesiculation, pustulation, moisture, 

i Centralzeitg. f. Kinderheilk., 1878, Bd. ii. 



PITYRIASIS RUBRA. 281 

or crusting;. The palmar and plantar surfaces are usually less dis- 
tinctly reddened than the face and extremities, having at times even 
a pallid hue ; but they are always covered with a distinctly scaling 
epidermis. 

Under pressure with the finger, the redness subsides or assumes a 
yellowish shade, while, as a rule, when the integument is gathered 
up between the finger and thumb, no thickening and infiltration can 
be recognized. Exceptions to this have been, however, noticed by 
several observers, the author among the number, in an interesting 
case made the subject of a clinical lecture. 1 The temperature of the 
skin is slightly increased. The exfoliation is, as the disease pro- 
gresses, one of the most striking of its characteristics, the scales 
accumulating in large quantities about the coverings of the body of 
the unfortunate patient, who is engaged, as a French writer has it, 
in the labor of stripping himself involuntarily of his epidermis. 

The disease persists for months and years, always more severe in 
expression as it advances, the papery scales being shed more abun- 
dantly and in larger flakes, leaving beneath them a smooth, shining, 
occasionally purplish or even cyanotic skin. In the cases observed 
by Jamieson, 2 of Edinburgh, and the author, the skin was so dark- 
hued as to suggest the color of the mulatto. Gradually the patient 
is conscious of an increasing sense of chilliness, as if deprived of 
sufficient bodily covering. The itching may be absent, moderate, or 
severe. There may be instead sensations of stiffness, burning, and 
tingling. Later, the integument seems to retract, as if insufficient 
to encompass the body, and becomes subject to fissure from extension 
and contact, while the lower extremities may even be cedematous. 
This retraction may be so marked that ectropion of the lid may 
ensue, and wide opening of the mouth become difficult. The hairs 
and nails lose their lustre, and become friable, often falling, though 
at times escaping altogether. 

The influence of this gigantic, epidermal catarrh, involving, as it 
does finally, every portion of the surface, does not fail, toward the 
end, to be perceived by the vital forces. Alternating chills and 
febrile processes, pneumonias of a low grade, colliquative diarrhoea, 
tuberculoses, subcutaneous abscesses, bed-sores, and even gangrene of 
the skin may close the scene. 

Hebra and Kaposi have together had under observation " about 
fifteen" patients affected with pityriasis rubra, who, w T ith a single 
exception, died from its effects. It will be seen thus that the disease 
is exceedingly rare. A few interesting cases have been reported by 
English authors. Among Americans, Duhring, George H. Fox, of 
New York, and the author, have published reports of cases. The 
disease is one of early or middle life, and pre-eminently of the male 
sex. 

The progress of the disease is both rapid and slow, lasting for years 

1 Pityriasis Rubra : Chicago Med. Journ. and Exam., Feb., 1881. 

2 Edinburgh Med. Journ., April, 1880, p. 879. 



282 DISEASES OF THE SKIN. 

and at times ending with relative rapidity. In the course of a few 
days after its onset the entire body may be covered with the exan- 
them ; and yet when the disease is of long duration it may be at 
times partial and at others general in distribution. There are no red 
points visible as in other forms of scarlatiniform-shaded eruptions, 
and the color when the palms and soles are involved only appears 
after the thick epidermis of those regions has once been shed. Sweat 
may or may not be secreted in stages of the disease. The tongue is 
bright red in color in the early stages ; later it is covered with a 
brownish crust. It is said at times to undergo a species of exfolia- 
tion. In a case lately brought before the author's clinic there was a 
very distinct history of a secretion which stained the linen at certain 
times. Rhagades may form, especially in the palmar and plantar 
regions. It is to be remembered that while typical cases of this dis- 
order first described in Vienna, never exhibited infiltration of the 
skin, this change has been observed in other typical instances. The 
nails may be separated, tilted up from the nail-folds, softened, 
thinned, fissured, " worm-eaten," or otherwise altered. The chief 
systemic symptoms recorded are : languor, chilliness, and even severe 
rigors alternating with febrile temperatures of recurrent type, albu- 
minuria, diarrhoea, pulmonary oedema, icterus, interstitial pneumonia, 
bronchitis, and rheumatism. 

The cases reported so freely and frequently by English authors, 
are mostly instances of exfoliative dermatitis following lichen ruber, 
eczema, psoriasis, and other simple dermatoses. In this class in 
particular, belong the patients reported as suffering from repeated 
attacks of the disease ; and those also in whom the disease is limited 
to but a few regions of the body, such as the palms and soles. 

Etiology. — The causes of the disease are absolutely unknown. 
It will be seen that the small number of cases which have been 
recognized furnish but an insignificant field for the study of the 
malady. It is more common in men than in women, and in adults 
rather than in children. It is interesting, however, to note in this 
connection, that the constitutional symptoms of each case seem to 
have been induced by the disease of the skin, and not the latter by 
any internal derangement of which the symptoms are made manifest. 
For not only do these visceral troubles occur chiefly at a late period 
of the malady, when common observation suffices to show that the 
cutaneous mischief alone is sufficiently extensive to induce them, 
but it is also clear, from the wide range of these disorders (bowels, 
lungs, etc.), that no special visceral malady has excited the cutaneous 
disease. 

Pathology. — The researches of Hans Hebra 1 have demonstrated in 
two cases that there is, in the earlier period of the disease, an infil- 
tration of the integument moderate in degree, succeeded at a later 
period by cutaneous atrophy, in which the rete and papillae of the 
corium disappear. The connective tissue elements undergo sclerosis ; 

i Vierteljahr. f. Derm. u. Syph., Heft 4, 1876, p. 508. 



PITYRIASIS RUBRA. 283 

and the glands and the follicles of the skin are destroyed. Pigmenta- 
tion is abundant. Both he and Fleischman have discovered coinci- 
dent pulmonary, intestinal, or cerebral tuberculoses ; and Kaposi, in 
one post-mortem examination, established an atheromatous condition 
of the arteries. 

Baxter ! in a case examined by him, discovered no trace of the 
stratum granulosum, nor was the stratum mucosum completely sepa- 
rated from the stratum corneum. There was a gradual transition 
from the polygonal prickle-cells below, which readily stained, to th 
horny cells above, which remained colorless. Flattened and faintly 
stained nuclei lay parallel to the surface, and could be recognized even 
in the enormously hypertrophied stratum corneum. The papilla? 
were enlarged ; the inter-papillary projections of the rete had pushed 
deeply into the corium. The prickle-cells of the hair-sheaths were 
multiplied. The remarkable consistency of the thickened corium at 
the outset of the disease was regarded by him as chiefly due to a 
fluid exudate, which was observed before death. 

Myelitis was recognized in one case by Jamieson, who has been fol- 
lowed by others in the recognition of central and peripheral neu- 
rotic alterations. 

Diagnosis. — It is clearly necessary to add to the facts given above, 
that many cases loosely reported as instances of pityriasis rubra are 
not really such. The misinterpreted symptoms are often those of au 
unusually extensive psoriasis or chronic squamous eczema, which 
commonly terminates favorably in the course of a proper treatment. 
Experts are often summoned to see such eruptions, whose import has 
been misunderstood. 

In lichen ruber the essential lesion is a papule, which even in the 
later extensive scaling of that disease usually may be recognized in 
some part or another of the infiltrated skin. 

Psoriasis rarely extends over the entire surface of the body, but 
it is at times thus generalized. In these very exceptional forms, 
a long history of typical psoriasic patches may usually be obtained, 
while the bleeding surface beneath the scales and the character of the 
latter will point to the true nature of the disease. Psoriasis occurs 
in healthy, pityriasis rubra in cachectic constitutions. Extensive 
erythematous or squamous eczema, apart from all other symptoms, 
can be recognized at once by the excessive distress occasioned by the 
eruption. The patient lies in bed nursing his or her tender limbs, 
back, or belly. In pityriasis rubra, the patient rises, dresses himself, 
and moves about with an expression, not of pain, but of listless 
apathy. His scales are not scanty and adherent, but abundant and 
exfoliating freely. There is, from first to last in his case, no history 
of moisture. In every generalized eczema there will be always, at 
one point or another, a surface which weeps. In its early periods, 
pityriasis rubra can be distinguished from pemphigus foliaceus by 
the absence of bullae and of the intolerable stench which is then 
often emitted by the sufferer. When, however, there is present 

1 Brit. Med. Journ., 1879. 



284 DISEASES OF THE SKIN. 

merely a generalized exfoliative dermatitis, the two disorders may be 
well-nigh indistinguishable. 

Treatment — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the exhibi- 
tion of this drug in prodigious quantities for long periods of time. 
Tar externally promises no better. Kaposi reports a single case re- 
lieved by the use of carbolic acid internally. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinia, is certainly indicated, with the simplest bland unguents 
externally. Of the latter, vaseline seems best tolerated. It should 
be employed, not merely to soothe, but also to protect the skin. The 
clothing should be ample and unirritating ; and the diet carefully 
selected with a view to supporting the strength. 

The Prognosis is necessarily grave. 



Pityriasis Rubra Pilaris. 
(Lichen Psoriasis.) 

Pityriasis rubra pilaris, or follicularis, is a desquamative affection of the skin- 
in which, while the general health may be unaffected, the cutaneous surface is 
altered in degrees varying from that in which numerous fine, dry, or greasy 
scales are shed from its surface, to that in which the latter is converted into a 
horny, dense, or coriaceous mass. 

This affection has been chiefly described in France by Devergie, 
Besnier, Bichaud, and others. The museum of the St. Louis Hospital 
is amply provided with illustrations in wax of every phase of the 
malady. In other countries it has either been described under a 
different name or been wholly ignored. Brocq declares that in 
America it is recognized under the title of lichen ruber. It is, in 
fact, a title given in France to a number of morbid conditions, each 
of which might receive a different name elsewhere. 

Symptoms. — It commonly appears as a seborrhcea sicca of the 
hairy scalp, with and without palmar and plantar scaling patches, 
though the face may be first to exhibit the signs of the disease. The 
eruption may be preceded by sensations of malaise, insomnia, hyper- 
sesthetic symptoms, or by a feeling of stiffness in the skin. The first 
symptoms are usually the occurrence of very fine desquamation ; 
soon after appear over the surface of the fingers, hands, forearms, 
elbows, knees, waist, or belly, minute papules, firm, dry, and silver- 
white, reddish-brown, or rosy-yellow in color. Each of these has 
evidently been pierced by a hair, and about its apex where thus 
traversed by the pilary filament there is a delicate sebo-corneous 
sheath which penetrates the follicle for a short distance. These 
papules may be as minute as a millet-seed or larger, but are never 
of the size of a split-pea. They become more and more numerous, 
appear at times to coalesce, and may form a patch covered with fine 
elevations, conical, discrete, or lost in the general scaling, exfoliating, 



PITYRIASIS RUBRA PILARIS. 285 

erythematous, or red and shining patch. The apex of each cone may 
display an unbroken hair, or a mere stump of the same, or a black 
point, the surface presenting then the appearance of the shaven 
beard. The yellowish-red or deep-reddish patches may be the seat 
of either pityriasic scaling, or may exhibit separation of the epidermis 
in large, adherent flakes, which over the elbows and knees particu- 
larly jDresent the appearance of a psoriasis. Commonly at the 
borders of such patches, there can be found without difficulty, the 
initial papules of the affection, still isolated and surrounding char- 
acteristic stumps, filaments, or black points of hairs, enabling one 
thus to make the diagnosis with ease. At times the eruption is com- 
pletely generalized ; when the face is chiefly involved, the slight 
crusts formed are decidedly of the type of those described under the 
title, eczema seborrhoicum. In many cases the tension of the skin 
w^hich results, produces ectropion of the lower lid. Occurring over 
the hairy scalp, the accumulated scales and crusts may produce a 
dense and resisting cap which is difficult of removal. The nails are 
usually grayish, yellowish, longitudinally striated, and roughened. 
There may be also a coincident polytrichia. Even, says Brocq, when 
the hands are completely invaded, one may discover on the dorsal 
face of the fingers, the little circumpilary cones of blackish hue, which 
serve to establish the diagnosis. The course of the disease is chronic, 
irregular, and subject to relapses and unexpected aggravations. The 
general health may remain unimpaired ; the itching is slight. 

Etiology. — The essential cause of the disease is unknown. It 
occurs rather more often in the male sex, but has been observed at all 
ages in both sexes. 

Pathology. — According to Jacquet, the papule which is the essen- 
tial lesion of the disease, represents merely a keratinization to an 
unusual degree, of the epithelial lining of the superior portion of the 
hair-pouch. All the other changes in the skin are subordinated to 
the epidermal affection. Besnier recognizes four different types of 
the disorder, three of which are probably represented by a somewhat 
different process in the corium and epidermis. These are : the 
sebaceo-squamous, or pasty form ; the reddish, or pityriasic ; the xero- 
dermic, in w r hich the condition resembles that known as "goose- 
flesh " ; and lastly a " mixed " form. It is in these clinical pictures 
that the process, if it be in fact unique, may be best recognized. For 
in these are represented the familiar changes seen in eczema, psoriasis, 
keratosis (or lichen) pilaris, xerosis, ichthyosis, and possibly a few 
other affections of the skin attended with keratinization of the 
epidermis. 

Diagnosis. — The disease is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, of 
a hair. Ichthyosis is congenital ; pityriasis rubra is more frequently 
generalized, and is a grave disorder affecting the general health, 
while pityriasis rubra pilaris does not interfere with the systemic 
condition. Lichen ruber acuminatus is by many supposed to be 
identical with the disease. For the differences between the tw r o 



286 DISEASES OF THE SKIN. 

maladies the chapter on the last-named disease may be consulted. 
Psoriasis is never characterized by papules with hair filaments in the 
centre. 

Treatment — The remedies hitherto found most useful in the local 
management of this disorder are those valuable in the management 
of psoriasis and squamous eczema. Tar, pyrogallol, chrysarobin, 
salicylic acid, and the mercurials, with lotions of Van Swieten's liquor 
are advised, and, when an inflammatory effect is produced, the employ- 
ment of soothing lotions and salves. Fatty crusts, when these are 
abundant, are to be removed by shampooings as in seborrheic affec- 
tions of the scalp. Internally, arsenic, cod-liver oil, and carbolic acid 
have not seemed advantageous. Brocq recommends for internal use 
the arseniate of sodium in increasingly large doses, but no single 
remedy is known to be efficacious when administered internally. 

The Prognosis is usually favorable. 



Epidemic Exfoliative Dermatitis. 

[Epidemic Skin Disease (Savill).] 

During the summer and autumn of the year 1891 an epidemic 
disorder with cutaneous symptoms developed in several of the 
London asylums, infirmaries, and hospitals, affecting about five 
hundred patients. The disease was studied with special care by der- 
matologists and other medical men. The brief sketch given below 
is based upon an excellent monograph with colored and photographic 
illustrations by Savill ;* various communications made on the subject 
in the columns of the British Medical Journal and London Lancet 
for the year 1892, and the description given by Crocker in his 
treatise. 

The disease occurred in two distinct clinical types, one with catar- 
rhal exudation from the skin, resembling the moist forms of eczema ; 
the other, dry and non- discharging, resembling pityriasis rubra, and, 
according to Crocker, indistinguishable from that disease. 

The eruptive features were apparently not preceded by prodromata 
but gastro-intestinal disturbance (vomiting, diarrhoea), and in some 
cases sore throat, either preceded or accompanied the appearance of 
the dermatosis. Except in patients of advanced years, there was 
usually post-occipital and cervical adenopathy, not to be explained 
as sympathetic with a cephalic eruption. The regions most frequently 
involved were the upper limbs, scalp, and face ; the lower limbs less 
frequently. 

The skin lesions were pruritic and were irregularly grouped, acumi- 
nate papules, with a follicular site. 

The stages of the exanthem as given by Savill were : (a) papulo- 
erythernatous, lasting from three to eight days, in which the papules 
were felt like shot beneath the skin, and were discrete, seated on a 

1 An Epidemic Skin Disease resembling Eczema and Pityriasis Rubra, by Thos. D. Savill, etc., 
London, 1892. 



savill's disease. 287 

reddened, thickened, even indurated or oedematous integument. In 
some cases the onset was in the form of marginate and circular 
nodose patches, resembling those seen in erythema nodosum ; in a 
few the resemblance was to ringworm, flattened papules enlarging to a 
circinate annular group with minute central vesicles readily ruptured. 

(6) An exudative stage. In this, lasting from three to eight weeks, 
papules, vesicles, or macules soon formed a confluent eruption, the 
skin being of crimson hue, thickened, and scaling in flakes, or in 
lamellated crusts in consequence of the exudation. In the moist 
type, the papules developed to vesicles with exudation ; in the dry 
type, the exfoliation occurred in purer scales, pints of which in cases 
could be collected from a patient's skin in a day. In some cases 
this exfoliation was in the form of an impalpable powder ; it was 
characteristic in some degree of all well-marked cases. 

(c) A stage of subsidence. In this, the disease proceeded to in- 
volution, leaving the skin at first indurated, polished, and brownish 
in color. In many cases, the new skin was raw and parchment-like, 
smooth, shining, and readily fissured, resembling in this respect 
ichthyosis. In a few instances ectropion resulted, as a sequel of con- 
junctivitis. In severe cases the hair and all the nails were shed. 
There was a mortality of from five to thirteen per cent., death result- 
ing from exhaustion with the usual signs of subsultus, shallow respi- 
ration, and coma. Complications occurred in the direction of pneu- 
monia, gangrene, and albuminuria. A few of the attendants upon 
the sick, children, and those of somewhat older years were attacked, 
but for the most part the patients, and especially those succumbing 
to the disease, were individuals of advanced years of both sexes, 
inmates admitted for the management of other disorders to the 
institutions where the disease prevailed. 

The Etiology of the disease was not satisfactorily determined. 
Cocci were isolated and cultivated by Savill and Russell, but the 
etiological importance of these micro-organisms is yet to be demon- 
strated. The influence exerted upon the disease by parasiticides was 
beneficial to a degree ; but the treatment on the whole was unsatis- 
factory and amounted chiefly to amelioration of the condition of the 
skin. 

Parakeratosis Variegata. — Under this title, Unna 1 and his 
assistants described two cases of patients affected with a dermatosis 
supposed to be idiopathic, occurring as a yellowish, reddish, or 
empurpled eruption lasting several years, and at first affecting the 
neck, chest, and lower limbs ; later involving the entire surface of 
the body with the exception merely of the head, palms, and soles. 
The infiltrated patches, which at times contrasted with apparently 
sunken areas of the intervening sound skin, were the seat of a 
pityriasic desquamation ; were distinctly circumscribed, and some- 
what variegated in color, suggesting the name. Beneath the scales 
the surface was smooth and brilliant. 

1 Mouatshft. f. prakt. Derm., 1890, vol. xi. 



288 DISEASES OF THE SKIN. 

Lichen Ruber. 

Gr., hei-xyv, moss. 

Lichen Ruber is an exudative cutaneous disease, characterized by the appearance 
of firm, millet-seed to split-pea sized, reddish, conical, flat, angular, discrete, or 
confluent papules, whose evolution may be accompanied by a moderate degree 
of itching, the eruption having a marked tendency to generalization and in 
cases to the induction of a fatal marasmus. 

Under the term Lichen Kuber, Hebra was first to describe the dis- 
ease which is now recognized under this title. It is a malady rare 
of occurrence ; yet more often recognized and described on the Con- 
tinent of Europe than elsewhere. Its exact relations to lichen planus 
and to pityriasis rubra pilaris have been the subject of extended dis- 
cussion, whose results have not yet definitely settled all the questions 
at issue. In these pages the disease is described as it exists in Europe, 
and from the point of view of the best authors of that country ; 
while the chapter devoted to lichen planus is designed to portray 
that affection as it exists in America and as it has been here investi- 
gated by American observers. 

Symptoms. — There are two varieties of this disease (1) Lichen 
ruber acuminatus ; and (2) Lichen ruber planus. 

(1) Lichen Kuber Acuminatus. — The disease is first charac- 
terized by the appearance, without prodromal symptoms, of isolated, 
pin-head sized, conical, reddish, and scale-capped papules of con- 
siderable firmness, bright red or livid in hue, and disseminated over 
the belly, chest, genitalia, extremities, and other portions of the body. 
In another form of the disease these lesions are lighter in color, with 
a smooth surface, a small central depression at the apex, and a waxy 
appearance. The " nutmeg grater" effect is usually produced when 
the finger is passed over them. The itching excited may be mild or 
severe. It bears no relation to the extent of the exanthem. 

The papules rapidly multiply, forming patches which by aggrega- 
tion rather than by coalescence, eventually cover entire regions of the 
body, and, lastly, its entire surface. Throughout all, the individual 
papules do not enlarge at the periphery, but persist as such till they 
are lost in a diffuse, dull-red, infiltrated patch, covered with thin, 
papery, grayish, non-adherent scales, beneath which the orifices of 
the hair-follicles are seen to be dilated. 

Occasionally at the borders of a patch thus formed, isolated, shining, 
flattened, or umbilicated papules persist or form circles of densely 
packed lesions, surrounding groups in which involution of the lesions 
progresses, leaving pigmented and atrophic areas within. 

Whether in the form of lesions last described, or after irregu- 
larly disposed disseminated patches have been developed, the entire 
integument becomes eventually the seat of extensive infiltration, 
reddening, and scaling. As a consequence fissures form ; and the 
distress of the patient increases. Bulla? are occasionally observed. 



LICHEN RUBER. 289 

The skiu of the face cracks ; the lids are everted or thickened ; 
the skin of the palms and soles is converted into leathery tissue ; the 
Dails become friable and irregular ; motion at the joints is excessively 
painful on account of the iu elasticity of the skin covering the articu- 
lations ; the hairs are thinned and fall ; the extremities are maintained 
in a position midway between flexion and extension. The integu- 
ment is now universally reddened, covered with innumerable deli- 
cate or coarser scales, and, especially upon the palmar and plantar 
surfaces, thickened by dense infiltration. Over the deeper fissures, 
extending to the corium, blackish and blood-containing crusts form. 
Emaciation progresses pari passu with the invasion of the disease ; 
and death may result from exhaustion, intercurrent diarrhoea, or 
pneumonia. 

(2) Lichen Ruber Planus (as a variety of lichen ruber acumi- 
natus) is described by most European writers as identical with the 
Lichen Planus of America. Minute yellowish to reddish papules, 
irregular, differing in shape but often polygonal, varying in size 
from the minutest lesions to those as large as a pin-head, firm, and 
dry, rise from the affected surface of the skin, often at the site of a 
hair-follicle whence the pilary filament has disappeared. Desquama- 
tion does not occur, as a rule, while these lesions are isolated ; when 
confluent, there may be considerable scaling. The itching may be 
mild or of intensest grade. 

The eruptive symptoms may persist as discrete as at the outset, the 
exanthem spreading by multiplication of new lesions till the entire 
surface is involved. At points there may be confluence with forma- 
tion of a flattish and elevated plaque, light or dark-reddish in hue, 
irregular in outline, with considerable infiltration of the integument. 
Grayish scales are then produced, often with whitish strise radiating 
from the patch. Annular bands are thus formed ; and other figures 
which may be geometrical in contour. Occasionally there are vesi- 
cles and vesico-pustules. Deep pigmentation may succeed complete 
involution of the disorder. The wrists, forearms, belly, lumbar 
region, inferior extremities, and in men the genital regions, are most 
often involved. 

The variations of the affection are : an extreme grade of exfolia- 
tion of the epidermis in large plates, with a raw, reddish surface 
beneath, surrounded by a fringe of reddish or yellowish scales. On 
the palms and soles the resemblance to the syphiloderm of these parts 
is striking. In other cases minute pits or depressions are left in the 
palms or soles where the epidermis has fallen. Iu other cases, 
according to Brocq's description, the papules exhibit blackish points 
in the centre corresponding to the orifice of coil-glands. It is also 
noted that the disease may affect the mucous surfaces, as is described 
in the ensuing chapter. The disease in Europe may progress in a 
chronic course even for months and years without marked modifica- 
tion. At other times the evolution is with great rapidity, the erup- 
tive elements being large, the skin greatly infiltrated, the sheets of 

19 



290 DISEASES OF THE SKIN. 

eruption vast, and the general distress great. Bulla? and vesico- 
pustular lesions are in rare cases observed. 

Mixed Forms are reported by several authors, in which all the 
symptoms of lichen ruber acuminatus and lichen ruber planus have 
been exhibited in one patient. In some the one form of disease has 
been noted to precede ; in yet other cases, another. Instances are 
recorded in which all the lesions of typical lichen ruber acuminatus 
and planus have been coincidently observed in one patient at the 
same time. 

Unna, of Hamburg, has attempted to create yet another clinical 
variety of lichen ruber, under the title Lichen Ruber Obtusus. 
In ^ a first variety, these are semicircular, pea-sized, flattened, 
polished waxy papules unprovided with scales, having a bluish-red 
or brownish-red depression in the centre. The itching is usually 
intense ; the papules may coalesce ; the eruption become generalized. 
Pigmentation has been observed after involution is completed. Occa- 
sionally cicatrices have formed. 

In a second corneous form, described by the same author, the 
papules are large and seated for the most part on the extremities. 
The itching is intense. As individual lesions increase in size, the 
tinting becomes brownish, and over these elements form small, grayish, 
dry, and adherent scales, which give a cornified aspect to the surface. 
Some of the papules persist without coalescence throughout the attack. 

These are evidently merely clinical variations of the disorder 
described fully by others. 

Lichen Ruber Moniliformis (Kaposi) is an odd-looking dis- 
order of the lichen ruber class, in which numerous node-like masses 
are arranged in lines and chains resembling the necklace of jewellers, 
with flattish, punctiform papules between the nodes, and macules of 
a sepia-brown hue interspersed between the two. 

Etiology. — The causes of the disease are unknown. The sexes 
seem to suffer in equal proportion, though it is claimed that more 
men than women are affected. The disease is neither transmitted by 
heredity nor contagion. In those who display the symptoms of the 
affection, external irritation is capable of aggravating the eruption. 
The disease is chiefly encountered in middle life from the tenth to 
the fortieth year, but has been observed as early as the eighth month. 
It is probably a tropho-neurosis. Cases have been reported following 
traumatism and shock. Well-marked instances of the disorder have 
been recorded in persons otherwise healthy. Lassar has discovered 
minute bacilli in the lymph spaces, but these have not been shown 
to be the effective causes of the malady. 

Diagnosis. — In psoriasis, the discovery of a typical scaling patch > 
often with a clearing centre, should suffice for recognition of that 
disease. The scaling also in diffuse psoriasis is much more abundant. 
In papular eczema, the lesions do not persist as such. When these 



LICHEN RUBER. 291 

two affections are generalized, it is claimed by French observers 
that there is always some one area, however small, of unaffected 
integument. This is not true of generalized lichen ruber. But, in 
such generalized cases, the distinction between that disease, pityriasis 
rubra, or dermatitis exfoliativa may be extremely difficult, if at all 
practicable or possible. At an earlier period, papules are not seen in 
either of the two last-named disorders. The papules of syphilis 
never scale so generally as those in lichen ruber ; they, moreover, in 
cases, iucrease to double their original size ; and are always accom- 
panied by some other symptom of that disease. In the scaliug stage 
of pemphigus foliaceus, there are bullse present or a history of such 
lesions pre-existing. 

Lichen ruber is to be distinguished from pityriasis rubra pilaris 
by the non-limitation of the former to the orifices of follicles ; by 
the later period of its scaling ; by its deeper involvement of the 
skin ; by its greater diffusion over the extensor surfaces of the body ; 
by its severe grade of pruritus ; by its involvement of the general 
system ; by its frequent grave issue ; by the deep pigmentation re- 
maining ; and by its occasional involvement of the mucous surfaces. 

Pityriasis maculata et circinata is a much more superficial and 
a milder affection ; its scales fewer; its rarer papules smaller and 
occurring chiefly at the periphery of its oval patches. 

Pathology. — Lichen ruber is a paratypical keratosis of the super- 
ficial portions of the stratum corneum. It is characterized by hyper- 
trophy of the stratum corneum and incomplete corneous transformation 
of the individual elements of that layer, which are larger and more 
polygonal, a feature most noticeable about the sweat-ducts and hair- 
follicles. The rete is in places enlarged in consequence of cell-infil- 
tration, and in places normal. The upper portion has an uneven 
appearance as the interpapillary portion pushes slightly downward 
and the increase in size of the other parts is more marked. The 
papilla? are increased in size ; their bloodvessels dilated and sur- 
rounded by emigrated corpuscles. The walls of the sweat-duct are 
formed of large cells with vesicular nuclei ; corneous cells are heaped 
also about the orifices of the hair- follicles ; the muscle-bundles are 
much hypertrophied. 

Treatment — Arsenic is of greatest value and can be employed with 
large chances of success in lichen ruber. The drug is to be early 
given, persistently pushed in the face of new crops of lesions till the 
desired result is obtained, and continued for several months after all 
signs of the disease have disappeared. Tonics, when indicated, should 
always be exhibited. The diet should be generous. 

The external treatment is naturally employed chiefly for the relief 
of any pruritic sensation. Here the dusting powders and ointments 
prove serviceable. The local remedies employed in corresponding 
stages of eczema may, in brief, be here used with advantage, such as 
the alkaline, starch, or bran bath ; followed by inunction of the skin 
with salves containing thymol, salicylic acid, zinc oxide, bismuth, 
carbolic acid, or benzoin. 



292 DISEASES OF THE SKIN. 

Prognosis. — The prognosis of the disease, when it refuses to yield 
to treatment and tends to become generalized, is necessarily grave. 
Treatment, after the occurrence of marasmus, will often prove in- 
effectual. The disease is said to be occasionally amenable to 
energetic treatment, before it has advanced to the stage of inducing 
systemic exhaustion. 

Lichen Planus, as it exists in America. — Lichen planus is 
a chronic and exudative affection characterized by the appearance 
upon the skin, of multiple, usually symmetrical, pin-point to split- 
pea sized, discrete or aggregated, flat, polygonal, yellowish, or pur- 
plish-red, smooth and glazed papules, having the appearance of 
umbilication at the apex. 

In the pages which precede, " lichen ruber planus/' as it exists 
in Europe and is denned by Europeans, has been briefly described. 
Under the title lichen planus are here given details respecting 
the disease, once quite rare, now more often recognized in this 
country. The statements which follow relate to this affection as 
it occurs in America and as it has been investigated by American 
observers. 

Symptoms. — The first symptoms of the disease are characteristic 
flat papules, which are glazed, waxy, umbilicated, scaling at the apex 
only after they have existed for some time, pin-point to rape-seed in 
size, and roundish, angular, or oval in contour. They are usually 
firm, and particularly well characterized by the minute punctiform 
depression of the flattened apex, described as an " umbilication." 
They are at first irregularly disposed, but later tend to arrange 
themselves in groups about the flexor aspects of the wrists and knee, 
the palmar and plantar surfaces, the lips, lids, cheeks, shoulders, 
penis, and other parts, as of the trunk and limbs. Often, as the 
lesions persist, they become flatter, assume a characteristic purplish- 
red or dark-brownish shade, and surround themselves with closely- 
packed, newer lesions in circlets or parallel lines. Jn this way, dis- 
tinct, sepia-tinted patches may form, whose progressive involution 
leaves dark-brown atrophic depressions in the skin, suggesting cica- 
trices. The itching may be moderate or severe. The eruption is 
chronic in its course ; tends to linger within distinctly circumscribed 
areas, and seems to exert upon the constitutional forces little or no 
influence. As it is amenable to treatment, it has been less studied in 
its unmitigated features ; but it may become generalized. Emacia- 
tion and other symptoms of disturbance of the general economy may 
result in such cases. 

Many lesions in the neighborhood of those well developed are the 
smallest papules recognized in diseases of the skin. They are no 
larger than the points of small pins, scarcely if at all elevated, and 
have either the color of the normal skin, or are whitish, lilac-tinted, 
or yellowish. They all, however, are, as Wilson first described them, 
" smooth, shining, and flat." The older groups may be either in 



LICHEN PLANUS. 293 

circles or bands of various lengths having a violet, or bluish-red, or 
even a coppery hue. 

The other special characteristics of the papules are their angular 
outlines and the adherent horny covering of each. As to the former, 
the characteristic singularity of the sides is most conspicuous as the 
papule becomes developed ; but even in the exceedingly minute pin- 
point sized lesions one may often with a glass detect the polygonal 
outline which later on can be distinguished with the naked eye. The 
surface of each is covered by a thin stratum of horny epidermis, 
which is not a true mass of scales, since it does not exfoliate. In 
some types of the disease, a patch, whether band-like or circular, of 
aggregated or well-developed papules, may include also an infiltrated 
interpapular skin, with a grade of inflammation which may result in 
severe general scaling, and with changes induced by the traumatism 
of scratching to relieve a consequent mild or severe pruritus. 

The course of the disease is decidedly chronic, but its lesions are 
rarely complicated by vesiculation, pustulation, or by changes in the 
hairs and nails. Upon the lower extremities, after it has existed for 
a long time, a single band-like plaque of the disease may lose almost 
all of the papular features, and come to resemble a deep purplish 
keloid-like elevation or flat tumor embedded in the skin, with whitish 
miliary points or streaks at the border. When involution is com- 
plete, there is usually very deep pigmentation and at times slight 
atrophy. 

Weyl describes the whitish points and streaks referred to above, as 
visible at times even in the smaller lesions, the horny scales projecting 
from others like thorns. Fantastic groups occur on the body in the 
form of a cockade or in a whip-shaped curve. The bands of papules 
also may assume odd and singular figures. At times, especially 
when the case is one of persistent and wholly discrete papules, linear 
bands of these, one or several centimetres in length, of geometrical 
straightness, may be commingled with curved lines and even S-shaped 
figures. 

When there are decided sheets of infiltration these are most con- 
spicuous over the flanks and belly, but they may also be seen else- 
where, as for example over the extremities. In these cases the very 
peculiar color of the patch with indefinite outlines is characteristic. 
It has a distinct crimson shade approaching the deeper purples, and 
this color is often in brilliant contrast with the scales. These are of an 
exquisite silvery whiteness, very different in hue from the pearl-white 
or yellowish- white large scales of psoriasis, and equally distinct from 
the branny and yellowish fine scales of pityriasis maculata et circinata. 
They are by no means freely shed from these extensive patches ; but 
adhere and rarely cover the entire patch, nor crop out beyond its in- 
definite border, but produce a species of silvery sheen over its cen- 
tral portions. These patches are usually symmetrical ; as are also 
commonly the discrete papules of extensive development. When 
either of these forms proceeds to involution, the scaling ceases, the 



294 DISEASES OF THE SKIN. 

infiltration subsides, and the intensely deep pigmentation left is 
characteristic of the disease, being often of a smoky, and even 
blackish, hue. 

In some cases the eruption is well-nigh generalized, and though 
itching may be absent in these extreme instances, it may be as 
intense and as intolerable as in any dermatosis attended with pru- 
ritus. It may actually constitute, especially in nervous women, the 
most formidable feature of the disease. 

The course of the disease in this country is always toward recov- 
ery ; and while it may endure for months, it is very rare indeed 
that it lasts for years, as the lichen ruber planus of Europe is re- 
ported to do. Also is it of the rarest occurrence that symptoms 
are presented in its course suggesting either pityriasis rubra pilaris 
or lichen ruber. 

Variations in the small or larger papules are occasionally ob- 
served. Minute vesicular points may be visible over their flattened 
surfaces, or equally minute keloid-like processes, or reddish points, 
upon or between them, where the vascularity of the tissues beneath 
is apparent. Only as an exception to the rule are the polygonal 
papules clustered about the orifices of hair-follicles as in pityriasis 
rubra pilaris and lichen ruber. At times whitish points and streaks 
are left after the resulting pigmentation subsides. The disease is 
rare in children, but a few cases have been observed at an early age. 
Bullae have been recognized as coincident features in but a few cases. 
Over the palms and soles the whitish spots produced by exfoliation 
of the epidermis may be the most conspicuous symptoms of the dis- 
ease in those regions. 

Lavergne divides all cases of lichen planus into three classes. The 
first is chronic lichen planus, the disease as it is known in its most 
common form. The second is acute lichen planus, in which the 
papules rapidly develop, and form extensive patches, thickened, 
painful, livid-red, and abundantly desquamating. The third form 
is the lichen planus corneus, of Vidal, Fournier, Besnier, and Heguy. 
It corresponds to the coin- or palm-sized, bluish to blackish, scaling 
and rugous, tumor-like plaques, usually seen on the anterior face of 
the leg, briefly described above. 

Pospelow 1 and Thibierge 2 have observed buccal lesions occurring 
in lichen planus of the mucous surfaces. Wilson, Hutchinson, 
Kaposi, and Crocker have described similar lesions, which are to be 
carefully differentiated from the patches of leucoplakia buccalis (so- 
called " psoriasis buccalis "), epithelioma, and the mucous patches of 
syphilis. The plaques are whitish, thickened, and uniform eleva- 
tions of the mucous surface, grayish-white, or resembling in color 
the places to which the nitrate of silver has been applied, with irreg- 
ular contours, often horizontally disposed between the teeth. These 
may be due to confluence of pin-head size papules of lichen planus. 

Etiology.— -The causes of the disease are obscure. It is seen in 

i Viert. f. Derm. u. Syph., 1885, p. 533. 
2 Annal. de Derm et de Syph., 1885, p. 66. 



LICHEN PLANUS. 295 

both sexes, and at all ages, but is decidedly more common in early 
and middle adult life. Debility, digestive disturbances, and neuras- 
thenia have all been named as effective causes ; but it is seen in very 
fleshy, middle-aged women and strong men. 

The evidence that connects this disease more directly with the 
nervous system is of great value, and aunually accumulating. In 
some cases, distinct coiucident neuralgias of the head and lumbar 
regions are reported. In yet others the papules have been noticed 
distributed in the areas supplied by given nerves, or occurring after 
injury of such nervous branches. 1 

Russell has lately reported a case in which the disease followed 
amputation of four fingers of the right hand. 

Pathology. — Robinson first clearly showed the pathological dis- 
tinction between lichen ruber and lichen planus. His observations 
have been confirmed by those of Bceck, Kaposi, Touton, Weyl, and 
others. 

The first changes noticed in the skin are increase in the lumen, 
and a sinuous condition of the capillaries supplying the one or two 
papillae concerned in a single papule. The papilla?, thus largely 
filled with dilated capillaries, also contain a network of fine connec- 
tive-tissue fibres, and dense, round cells, which proceed to multiply. 
Later, more papillae are concerned in this process and also the epi- 
dermis. In the places where the white points are exhibited, gran- 
ules of kerato-hyalin become visible. In some portions of a lichen 
papule of medium development, the stratum corneum exhibits an 
external, dark, narrow, and firm layer, and beneath it two to four 
rows of translucent cells forming the stratum lucidum ; but in other 
parts, and when fully developed in all parts, the stratum corneum 
breaks up into definite lamellae, a phenomenon seen in other disor- 
ders attended by derangement of the kerato-genetic function of the 
skin. The external layer is dark, when stained, and firm ; next 
below it is a wider layer of swollen cells with nuclei scarcely visible, 
or relics of liberated nuclei ; and, still deeper, a narrow and solid 
layer beneath which the stratum lucidum becomes visible. 

In Robinson's sections, the horny layer was almost entirely absent 
over the region occupied by the cell-packed papule, below which the 
corium was normal. The rete was hypertrophied centrally, espe- 
cially in the region of the sweat-ducts ; its cells above the affected 
papillae horizontally flattened, and the granular layer thickened. In 
some places it was difficult, in consequence of these changes to dis- 
tinguish betweeu the rete and the corium beneath. The cell-infil- 
tration, composed largely of embryonic white blood-corpuscles, 
extended more deeply into the corium in the neighborhood of the 
sweat-ducts. 

Briefly, it appears that the papule of lichen planus is the result of 
a primary hyperemia of the papillae of the corium ; a secondary 
thickeuiug of the lower part of the rete ; a tertiary flattening of the 
papule by reason of the resulting pressure, producing thus the 

1 See Report of Two Cases, by Dr. Stephen Mackenzie, Journ. of Cutan. and Ven. Dis., 1885. 



296 DISEASES OF THE SKIN. 

appearance of umbilication ; a proliferation of cells in the granular 
layer, as a result of which the deposit of kerato-hyalin in whitish 
points or sheets occurs sufficient to produce the clinical peculiarities 
having that appearance (not due, as Neumann supposed, to changes 
in the sweat-glands) ; and coloration of lesions due to both vascu- 
larization and to escape of blood corpuscles. 

Diagnosis. — The diagnosis rests on the characteristic shape, size, 
color, grouping, disposition, and umbilication of the papule of lichen 
planus ; which are not found in any other papular disease. Thus, in 
its size, apex, color, and course, the papule of papular eczema is quite 
different from that described above, being brighter, redder, more 
acuminate at the apex, and much more often followed or accom- 
panied by catarrhal symptoms. In psoriasis punctata, the scales are 
abundant and readily removed ; the individual lesions also increase 
rapidly by peripheral extension, far beyond the fullest development 
of the papule of lichen. The papular syphiloderm is not, as a rule, 
pruritic, not flattened when minute, not polygonal in shape, not 
covered with a closely adherent horny scale, and always occurs in 
patients where careful investigation will disclose other symptoms of 
the disease (mucous patches, adenopathy, etc.). 

Treatment. — Roborant treatment by quinine, the mineral acids, the 
ferruginous tonics, and cod-liver oil, is frequently indicated. Though 
it is claimed that arsenic actually aggravates the disease, the author 
agrees with Hebra, Wilson, Dubring, and others, in ascribing to it 
the most brilliant results obtained in the treatment of lichen planus, 
results far more consistent than are obtained from the same drug in 
the management of psoriasis. Boeck and Taylor give fifteen grains 
(1.) of the chlorate of potassium in four ounces (128.) of water, 
fifteen minutes after eating, followed in a quarter of an hour by 
twenty drops of the dilute nitric acid, swallowed in a wineglassful of 
water. Robinson, in generalized and hypersemic cases, praises the 
alkaline diuretics (acetate of potassium with sweet spirits of nitre), 
well diluted after meals ; and Fox regards mercury as valuable in 
the chronic forms of the disease, for which also he administers asa- 
fcetida. Koebner has injected both pilocarpine and arsenic subcuta- 
neousiy with success. 

In the way of local treatment Unna has used one part of corrosive 
sublimate, twenty parts of carbolic acid, and five hundred of the 
benzoated oxide of zinc salve ; Vidal employs baths of vinegar, one 
litre to the bath ; and the external application of one part of tartaric 
acid to twenty of the glycerole of starch ; and Wilson employed a 
mercurial salve, two grains (0.13) to the ounce (32.). Tar, ichthyol, 
thymol, iodine, and chrysarobin may also be successfully employed 
topically. Weyl has employed caustic applications ; as also one or 
two parts of beta-naphthol to ninety of rectified spirits of wine, 
and ten of glycerin. 

Prognosis.- — The prognosis is always favorable, as the disease, even 
when chronic, tends to spontaneous disappearance. 

Where the skin is highly sensitive, the itching severe, and the 



ECZEMA. 297 

eruption rather abundant, it is safe to treat the case as an acute or 
subacute eczema. The alkaline baths are grateful, followed with 
emollient powders ; or the diachylon or zinc salve. Often modified 
pastes (two parts each of zinc oxide and talc with four of vaseline, 
and one or two per cent, of salicylic acid) answer admirably. The 
pigmentation left after the involution of the disease, is best managed 
by gently stimulating the cutaneous surface with weak spirit, or salt 
and water lotions. 

Eczema. 

Gi\, en feu, to boil forth. 

(Ger., Eczem ; Fr., Ecze'ma.) 

Statistical frequency in America, 30.430. 

Eczema is a non-contagious, acute, or more frequently chronic, inflammatory dis- 
ease of the skin, beginning as an erythema, or by the appearance of isolated 
or grouped papules, vesicles, or pustules, either singly, simultaneously, or in 
succession, resulting in redness, catarrhal symptoms, scaling, crusting, and in- 
filtration of the skin, accompanied by more or less intense itching and burning 
sensations, and leaving, after complete resolution, no cicatrices. 

Symptoms. — Eczema is one of the diseases of the skin of most 
frequent occurrence. In the statistics gathered by medical men, it 
would seem to rank first in the order of frequency. But it is only 
true as regards those diseases for which the physician is commonly 
consulted. It is easy to become convinced that acne is a more fre- 
quently encountered affection than eczema, by observation of the faces 
of individuals on the streets of any large city, eczema being of more 
frequent occurrence in this situation than upon other parts of the 
body. Many persons are the subjects of acne who never deem it 
necessary to submit to treatment for its relief, and the records of such 
cases do not figure in dermatological statistics. This being noted, 
eczema may be regarded as the disease of the skin for which most 
frequently the practitioner of medicine is consulted. By as much as 
inflammation is the most common accident of other organs of the 
body, by so much is its enveloping organ subject to the same patho- 
logical process. 

The surgical signs of inflammation of any given tissue are usually 
named as increased heat, redness, pain, and swelling. These are 
essentially the symptoms of an eczema ; and it will be necessary, in 
order to study the disease intelligently, to inquire how these pheno- 
mena are modified by the anatomical peculiarities of the organ in 
this case affected. A typical eczema is always betrayed by an eleva- 
tion of the temperature of the surface, and by a greater or less 
degree of swelling. Redness, in various shades, is also true of the 
eczematous skin. Pain here is represented by a sensation usually of 
itching, which may vary from slight annoyance to an almost intoler- 
able distress. The variation in the sensation which accompanies 
inflammatory disorders of the skin and other organs is merely due 



298 DISEASES OF THE SKIN. 

to the fact that the former is exposed to the air, and its increase in 
bulk is not opposed by other contiguous parts, as, for example, the 
inflamed bone in contact with periosteum, or the pathologically 
enlarged prostate within its fibrous capsule. Inflammation of the 
inner skin of the body, as of the lining membrane of the stomach 
or of the intestines, is generally characterized by the occurrence of 
increased heat, redness, swelling, and severe pain. 

Inflammation of tissues constituting other organs of the body 
usually terminates either in resolution, in the free production of pus, 
or in the occurrence of gangrene. And so an inflammation of the skin 
may terminate either by resolution, or by the free production of pus on 
its surface, the living matter rapidly multiplying as the intensity of the 
process may determine. Gangrene is not a classical result of eczema, 
chiefly because of the freely exposed position of the organ affected. 

The great variety of expressions assumed by an eczematous dis- 
ease, and the frequent interchange of these, the one for the other, are 
to be accounted for in the same way. The atmosphere which sur- 
rounds the body is but one of many external agencies capable of 
affecting the skin. Thus it is rubbed and scratched, exposed to the 
friction of the clothing and the incursions of insects, and subjected 
to innumerable injurious contacts in all the various trades and occu- 
pations of life. If the inflamed skin could be as perfectly protected 
from the outer world as is the spleen, we should find the history of 
this affection much simplified. 

Clinically, several types of eczema can be recognized. These re- 
quire separate description. It should not be forgotten, however, that 
each may prove to be not a variety, but a stage of the disease, which 
may speedily give place to yet another. 

[A.] Eczema Erythematosum. 

In this form of the disease the conspicuous symptoms are heat, 
redness, and swelling, with a variable degree of itching, usually less 
severe than in several of the other phases of the malady. The pro- 
cess may begin with acute and intense symptoms, to be soon followed 
by one of the varieties of the disease to be subsequently described, 
or, what is perhaps more commonly the case, may continue indefin- 
itely as a subacute or even chronic affection. In color, the skin of 
the part involved varies from a light to a darker shade of red ; and 
inasmuch as the process is more frequently observed in middle-aged 
adults, with darker hue of the integument than in early life, the 
color of the part is frequently noticed to be of a dull shade. In 
consequence of the swelling, the affected surface is notably elevated 
above the level of the unaffected contiguous skin, and the line of 
demarcation between the two can be more readily traced than in 
several of the other varieties of eczema. The surface is usually uni- 
formly and occasionally symmetrically involved. Lesions, other 
than the erythema, which is the prominent feature of the attack, may 
not be observed ; and, as a consequence, from the beginning to the 



ECZEMA. 299 

end of the disease, there may be no history of moisture. But in 
many eases, minute poppy- to rape-seed sized papules become visible 
on close inspection, still more rarely with a very minute vesicular 
apex filled with a droplet of clear serum. The localities chiefly thus 
involved are the face, the palms, the soles, and the regions about the 
genitalia, though any portion of the body may be affected. Resolu- 
tion is accomplished after the occurrence of a very fine superficial 
desquamation of the epidermis, or by very gradual diminution of the 
redness and swelling without the production of scales. In either 
event the termination of the process is often announced by significant 
changes in the involved surface, as by the fading of color, the ap- 
pearance of islets of sound skin between affected patches, and by 
perceptible relief in the subjective symptoms. 

Such is the course of a typical erythematous eczema. Variations 
from this type are, however, numerous and important. Thus the 
disease may be limited to a patch as small as a finger nail, or may 
extend over larger areas, especially after subjection to irritation. At 
times the coloration is irregularly distributed, producing a mottled 
appearance, brighter at one point and darker at another, while again, 
as has been indicated, the variety described may coexist with, or be 
followed by the weeping, excoriation, and crusting which are charac- 
teristic of other manifestations of eczema. Scratching of the part 
involved produces a change in the symptoms which the skilled eye 
will promptly recognize. Minute superficial losses of tissue are then 
visible here and there upon the surface ■ the fresher with a reddened 
floor possibly hidden beneath a thin blood-scale, the older surmounted 
by a light yellowish-red crust. The scratch-lines, so often recogniz- 
able elsewhere, are here less frequently evident. 

Like all the other varieties of eczema, this is extremely liable to 
recrudescence and relapse. In advanced life, the traces of the dis- 
ease may be visible for years. 

[B.] Eczema Papillosum. 

Under this title are classed all those forms which have long been 
described as Lichex Simplex, Lichen Eczematodes, Eczema 
Lichexodes, etc. " Observation of the natural course of an attack 
of eczema/' said Hebra, " furnishes the most unassailable proof of 
the connection between its various forms. In one case an eruption 
of vesicles begins the series of symptoms ; in another, it is preceded 
by the appearance of red scaly patches or groups of papules ; or 
vesicles and papules are developed together, some of the former 
rapidly chauging to pustules, and forming yellow gum-like crusts by 
the drying up of their contents." It is of the greatest importance 
that there should be a distinct and more general recognition of the 
fact, that eczema may exist from first to last as a dry infiltration of 
the integument, for there is perhaps no one of the various manifesta- 
tions of the disease that is so frequently mistaken and confounded 
with other widely different affections. 



300 DISEASES OF THE SKIN. 

The poppy- to rape-seed sized papules which are developed in its- 
course, are usually seated upon a reddened and thickened base, and 
are themselves colored in various shades of red to a dark lurid shade. 
They are usually discrete, though often closely set together ; are 
accompanied by a severe form of itching when irritated by scratching, 
and of all eczematous lesions are most apt to be thus irritated. Their 
summits are torn, and often to such an extent as to bleed, the blood 
drying in reddish crusts over the area involved, or limited to minute 
blood-scales on the apices of individual lesions. The extent of sur- 
face affected varies, as usual in the other varieties, being in cases 
largely diffused in patches over various portions of the body, or 
limited to small and single patches no larger than a silver quarter of 
a dollar. Such patches, covered with a single or several groups of 
reddish papules, may continue to torment the patient for long periods 
of time, or being at one time relieved, recur with each aggravation 
of the part by the exciting cause. Papular eczema is the dry mani- 
festation of the disease, and is thus most frequently noticed upon the 
drier portions of the integument. These are the surfaces of the 
limbs, the back of the body, and, in particular, the scrotum. In the 
latter region, the lesions giving a name to this variety of the disease 
are most fully developed. If the moist forms of eczema are most 
frequently seen in early life, it is none the less true that the dry 
forms are the most common in adult life or advanced years. 

It should not, however, be forgotten that the papules here described 
may develop into minute or larger pustules, or may exhibit minute 
vesicular summits when there is free exudation beneath the surface. 
It should be added, that a patch of papular eczema, where no vesicula- 
tion nor pustulation has been observed, will, if sufficiently scratched, 
ooze with moisture, the serum escaping from the abraded surface. 

There are, in fact, few scratched eczematous surfaces which will not 
moisten a dry handkerchief applied to the part. This weeping con- 
dition attracts the attention of patients themselves, who will complain 
of it in describing their symptoms to a physician. A certain species 
of relief for the pruritus is thus obtained ; and in aggravated cases 
patients will scratch, or rub, or otherwise irritate their diseased 
patches, not merely for the purpose of gratifying the intense desire to 
assuage this symptom, but also to induce the serous exudation for 
the sake of the relief it affords. The secretion when in contact with 
linen cloths, stains and stiffens them, very much as seminal fluid 
leaves its traces upon the clothing. 

Eesolution of papular eczema is accomplished after the formation 
of scales, the tissue beneath the latter assuming more and more the 
appearance of healthy skin. 

[C] Eczema Vesiculosum. 

This variety of the disease is, as its name implies, characterized 
at an early period by the formation of minute vesicles. It is a matter 
of importance, however, to recognize the fact that the vesicular, like 



ECZEMA. 301 

the erythematous, is but oue of several manifestations of this singu- 
larly protean affection. Long after the appearance of the treatises of 
the early English dermatologists, the term eczema was very generally 
limited by physicians to the vesicular phases of the disease ; and it is 
to the Vienna school that we are largely indebted for the recognition 
of the fact that these simultaneous or successive features, presented 
often in the same individual, really belong to one and the same 
malady. To limit the name eczema to-day to its vesicular variety 
alone, would be to relegate the student of diseases of the skin to the 
misty uncertainties of the last half-century of dermatology. 

The clinical features of vesicular eczema are chiefly due, first, to the 
acuity of the inflammatory process present ; and second, as a result 
of the former, to the free exudation of the serum of the blood from 
the vascular plexus immediately below the pars papillaris of the 
corium. The involved surface usually feels at the outset hot, itchy, 
or particularly sensitive, and soon after becomes more or less intensely 
reddened, the hyperemia producing this effect in the course of a 
true exudation which may last for one or several hours. Poppy- to 
rape- seed sized vesicles then become visible on this reddened base. 
The lesions may be closely packed together, or discrete, or may be 
so abundant as to coalesce, a frequent behavior of all vesicular 
lesions. Each is filled with a droplet of clear serum, imprisoned 
beneath the most superficial layers of the epidermis. The vesicle is 
readily ruptured, and, if this does not speedily occur as the result of 
accident, it bursts spontaneously, and its limpid contents are then 
poured out upon the surface of the integument. The quantity of 
the fluid thus exuded is in excess of that originally contained in the 
small vesicular chamber. This is due to the fact that the elevated, 
macerated, and broken epidermis no longer presents an obstacle to 
the outflow of the serum from the engorged vessels beneath. Minute 
and even large drops of a clear fluid of syrupy consistency can be 
seen forming at the points where the solution of continuity has 
occurred. If with a slip of bibulous paper the first drop be removed, 
its place is visibly filled by a second. Crops of new vesicles succeed 
the first, each followed by the train of symptoms described. The 
weeping at many points of the surface thus affected is so prominent 
a feature of the disease, that it has led several authors to describe 
eczema as invariably a catarrhal disease of the skin. There are, 
without question, forms of the disease where the history is throughout 
entirely different from that just described, where no evidence of 
discharge can be appreciated from first to last, and yet where, by 
artificial measures, the so-called catarrhal features can be readily 
produced. 

The subjective symptoms of the vesicular forms of eczema are more 
or less intense itching and often burning. In the very acute forms 
there is considerable soreness, the patient managing the affected part 
with as much care as if it were a fractured limb. In exceptional 
cases, more frequently observed in children, there is sympathetic 
febrile disturbance of a mild grade. 



302 DISEASES OF THE SKIN. 

The discharge from the broken epidermis, whether directly from 
the vesicles, or from the vascular elements, dries rapidly when exposed 
to the air, in light yellowish crusts, which are rarely bulky. The 
extent of surface involved is variable, and the contour of the affected 
patch or patches is seldom well defined, these portions imperceptibly 
shading into the sound skin. The color of the area thus diseased 
varies according to the stage of the process, being at one time of a 
bright and vivid red, at another yellowish, and when covered with 
crusts or scales, undergoing a corresponding change of hue. Infiltra- 
tion of the skin occurs rapidly, so that when a portion of the affected 
integument is pinched up between the finger and thumb, it is found 
to be thicker and less elastic than before. 

As resolution approaches, all the symptoms described above grad- 
ually decline in severity ; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen and fall, and beneath the scales which have taken the place of 
the oozing and broken epidermis, a new and tender epithelial cover- 
ing is produced. As a rule, for weeks after the process has com- 
pletely ceased, the newly formed epidermis has a slightly reddened 
and tender appearance, though complete resolution is followed by 
no permanent sequelae. 

Such then being the typical phases of vesicular eczema, it must not 
be forgotten that clinically the picture may be quite different from 
that described. The types here given are convenient for analysis 
and study, however they may be commingled and obscured in the 
inflamed integument. Like the erythematous, the vesicular forms of 
eczema may precede the others, and becoming chronic, torment the 
suffering patient continuously for long periods of time, or yield, only 
to reappear at irregular intervals. 

[D.] Eczema Pustulosum. 

This variety of the disease has also been termed Eczema Impetigi- 
nodes and Impetigo Eczematodes. It may originate in one of the 
other forms of eczema, which, in consequence of the severity or 
acuity of the process, changes from an erythematous, papular, or 
more commonly vesicular type; or pustular lesions may rapidly 
form at the onset. Usually a crop of minute vesicles is first seen of 
the sort just described, which, after enlarging to the size of a coffee- 
bean, become distended with puriform contents. These either acci- 
dentally or spontaneously burst, and the fluid with which they were 
distended dries into yellowish-green or darker-colored and friable 
crusts. In aggravated cases the purulent matter seems to form 
directly upon the surface involved. If the process be long continued, 
infiltration occurs ; and the itching, which in all varieties of the dis- 
order is a characteristic feature, is awakened as an accompanying 
symptom. It is, however, rarely of the peculiarly aggravated type 
which accompanies the erythematous and papular phases. Pustular 
eczema is most frequently encountered in the region of the head, and 



ECZEMA. 303 

in constitutions where there is a pyogenic tendency. When existing 
on the scalp and face there is most commonly an involvement also of 
the sebaceous glands, whose secretion, altered by the peri-glandular 
inflammation, is added to that naturally produced by the exudative 
process. Singular shades of mixed yellow and green, and even black, 
are then to be distinguished in the resulting crusts, which later desic- 
cate and fall, leaving a reddened and tender new epidermis beneath. 

Pustular eczema, as thus observed, has been described under a great 
variety of titles. Its identity as a form of eczema was first accurately 
distinguished by Hebra, in his experiments on the artificial produc- 
tion of the disease upon the surface by the external application of 
croton oil. It has been called Impetigo Figttrata, Mellitagra, 
Porrigo Larvalis, and other singular names, which suggest the 
attempts of the early astronomers to designate the constellations by 
their resemblance to the figures of animals. These, and many other 
useless terms, have been finally dropped from the nomenclature of 
modern dermatology. 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and un mingled forms 
of cutaneous disease, some of them more commonly than others. 
To present, however, a picture of eczema as it is seen clinically, it 
must be understood that these several forms, useful in the analytical 
study of the disease, often become, in actual observation, well nigh 
inextricably commingled. It is this untiring interchange of features 
which distinguishes all the results of manifold causes operating in 
nature at one aud the same time ; and it is this which gives the 
inflammations of the human skin, exposed to almost every external 
influence, such a manifold physiognomy. 

Like all other inflammations, eczema may be acute or chronic. 
Like all others, too, the acute may precede, and the chronic follow ; 
or the reverse may occur, the disorder, originating in subacute or 
insidious forms, may become chronic, and then, as the result of fresh 
or more severe irritation, develop into the acutest symptoms. Thus 
the name 

Eczema Rubrum 

has been given to the red and angry form of the disease, which, 
because of the free exudation of serum from its surface, has been also 
termed Eczema Madidans. In this form the intensely red and 
wounded integument pours out freely upon the surface a thick gummy 
or syrupy fluid, which, if artificially removed, leaves behind it the 
swollen, angry, and still discharging skin, or, being permitted to dry 
where it has formed, concretes into the thick, dark-colored and often 
blood-stained crusts already described. 

Again, the scales which usually form on the eczematous skin toward 
the conclusion of the process just described, may prove to be the 
most characteristic feature of the case from the first. Thus on the 
back of the neck an eczematous patch may often be seen, where the 



304 DISEASES OF THE SKIN. 

skin is infiltrated and covered with a stratum of thin, whitish scales, 
the latter having developed rapidly upon an erythematous surface, 
and continuing for a long period as a scaly disease. It is to this and 
similar forms that the term 



Eczema Squamosum 

has been applied. Again, in the regions about the hand, the move- 
ments of that organ often produce fissures or cracks in the inflamed 
and infiltrated integument, and to these fissured forms the term 

Eczema Fissum, or Eczema Rhagadiforme, 

has been applied. They are observed wherever an eczematous dis- 
order has so impaired the elasticity and extensibility of the skin, that 
its necessary movements, especially about the joints, tear and stretch 
the thickened integument. It is thus seen not only on the hands, but 
also on the feet and about the ankles, the resulting rhagades being, 
at times, the most painful of all the complications of the malady. 
Occurring upon the bodies and the hands of those who are compelled 
to come into contact with irritating substances, this form of the dis- 
ease finds its severest expression. 

Eczema Intertrigo 

is a name applied by several authors to that form of intertrigo which, 
surpassing the limits of hyperemia, results in an exudative process. 
Eeference is made to this possibility in describing the symptoms of 
erythema intertrigo, in a preceding chapter. Here the symptoms 
are usually those of diffused redness of surfaces of the skin in close 
apposition, macerated by previous transudation of sweat, and 
weeping with the serum which oozes from the several abraded points 
or patches. 

Eczema Verrucosum, 

or the wart-like form of the malady, is occasionally observed, espe- 
cially upon the lower extremities, in middle life or advanced years, 
as the result of long-continued disease. The integument becomes 
thickened and so hypertrophied as to suggest the appearance of warts 
closely packed together in a circumscribed patch. 

Eczema Sclerosum 

is a form of the disease most frequently observed upon the palmar 
and plantar surfaces, a condition referred to in the paragraphs relating 
to asteatosis. Here is presented a densely thickened inelastic in- 
tegument, suggesting the condition of tanned leather, without the 
occurrence of any of the other lesions of eczema described above. 
As a consequence, the perfect extension of the digits is impaired. 



ECZEMA. 305 

Eczema also occurs with acute and chronic manifestations. These 
are, as has been seen, interchangeable conditions, the types of which 
possess, how T ever, a clinical distinctness. 

Acute Eczema. 

Iu certain cases an acute attack of the disorder is ushered in by 
malaise, chilliness, or the recognized symptoms of the febrile state. 
With or without these prodromata, the affected portion of the surface 
becomes the seat of a burning sensation which is soon succeeded by 
redness and swelling. This may occur upon one or several portions 
of the body at the same moment of time, and the disease throughout 
be limited to this single area or these several spaces ; or it may extend 
from one or all to other regions. This extension may proceed by 
continuous development of the disease along the surface, or an eczema 
of the thigh be suddenly followed by an eczema of the face, and this 
by an eczema of the scrotum. According to Kaposi, extension of 
eczema by the last-described method is due to the extraordinary sen- 
sitiveness of the skin when involved in an acute attack, in con- 
sequence of which the slightest friction, and even reflex irritation of 
the bloodvessels, produces a new focus of the disease at a distant point. 

This is a consideration of special importance. Patients will fre- 
quently point to an acute eczema upon several portions of the body 
widely separated, the one from the other, and urge this as an irrefut- 
able argument in favor of the fact that they suffer from some " poison 
in the blood." 

The tumid and erythematous surface already described soon 
assumes the features of either papular or vesicular eczema, which need 
not be again detailed. In this manner the evolution of the disease 
occurs, and may continue for weeks, the patient, if unrelieved, tor- 
mented by the itching ; and, if the disease be extensive, prevented 
from attending to his usual vocation. Acute eczema of severe grade 
will frequently prostrate a strong adult, confining him to his bed- 
chamber and often to his bed. When there is a simultaneous febrile 
process the emaciation and adynamia are proportioned to its severity. 
Weeks and even months may elapse before recovery can be pro- 
nounced complete, subacute patches of the disease lingering here and 
there upon the surface, crust-hidden, scale-covered, occasionally oozing 
from recrudescence of symptoms. Recovery, even when complete, 
leaves the patient, it should never be forgotten, with a skin sensitive 
to irritation and more prone to a fresh attack of the disease than one 
long virgin of an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade. 
Needless to say that a circumscribed patch of the skin may exhibit all 
the features of vesicular eczema in an acute form ; and, under the 
influence of an appropriate treatment, be satisfactorily relieved in 
the course of a few days. Lastly, acute eczema may be followed by 
chronic forms of the disease, the one passing into the stages of the 
other by scarcely definable gradations. 

20 



306 DISEASES OF THE SKIN. 



Chronic Eczema. 

The symptoms and pathology of chronic eczema are largely those 
of the acute form of the disease. The chief differences to be noted 
relate to diminished intensity of the inflammatory action, or marked 
tendency to recurrence and persistence of the process, and a pre- 
ponderance of scaling and infiltration as contrasted with the active 
secretion and crusting of the acute phases. It is, however, important 
to remember that chronic eczema is not only the frequent sequel of 
such acute phases, but is particularly prone to recurrent exacerbations 
of acute grade, during which the serous discharges, consequent crusts, 
and angry aspect of the affected surface, do not fail to reappear. The 
itching so characteristic of the malady in all its manifestations is here 
also a tolerably constant symptom. 

Chronic eczema may involve a limited surface of the skin, or 
invade the entire surface of the body from the head to the feet. 
Rarely thus generally developed, it is more frequently observed upon 
circumscribed patches of the integument, as, for example, the scrotum 
or flexor surface of a joint, in which situation it may linger for years, 
or even for a lifetime, now better and now worse, or disappearing 
for brief periods only to return with each recurrence of its cause. 

Eczema Seborrhoicum. 

This term is applied by Unna to a clinical combination of symp- 
toms to which Piffard has given the name, Sudolorrhoea. As the 
several dermatoses represented often present a distinctive morbid 
aspect in the skin, they are well studied as a group. 

The chief sites of the process are the scalp, the axillae, the eyelids, 
the bend of the elbow, the groins, the cruro-scrotal angle, the back, and 
the shoulders. The onset of the disorder is particularly insidious or 
scarcely noticed, and when attention is attracted to it there is usually 
on the scalp a thinning of the hairs, moderate or really annoying 
pruritus, and scanty crusting or scaling of a poorly-defined or well- 
contoured patch, where there may be moderate infiltration. When 
examined the hairs are found to be dry and often thinned, and the 
scales or crusts (for it is often difficult to decide whether they should 
be denominated by the one term or the other) are distinctly 
fatty or greasy. There are several types of the disorder which may 
be arranged in the following classes : In the first, the symptoms are 
scarcely to be distinguished from those of alopecia pityrodes or pity- 
riasis capillitii. The affection may begin and end as such, limited 
throughout to the scalp, really a seborrhoea of that region with added 
exudative symptoms and the itching, burning, and other signs of the 
eczematous process. 

In a second class there is not only involvement of the scalp, but 
extension from it to the ears, temples, forehead, neck, and other parts 
adjacent. The skin is seen to be reddened beneath the yellowish- 



ECZEMA. 307 

white scales which, though not of great size, are decidedly abundant, 
and at times, freely shed from the surface. The limitation of the 
area of the disease (as distinguished from most eczemas) is, apart from 
the scalp area, remarkably distinct, so that for example, about the 
temple or ear, or along the forehead, one may define the line of ad- 
vance with a pencil. Occasionally, a distinctly catarrhal discharge 
flows from or concretes upon the part affected, being, however, 
different from that found in simple eczema because of its greasy char- 
acter, It is an admixture of sweat, sebaceous secretion, and a serous 
exudation. The "corona seborrheica" is a yellowish or reddish- 
yellow circlet of fatty crusts, formed in this way over the brow. 

In a third class, the eczematoid symptoms are more marked, the itch- 
ing more intense, the scratching induced more severe, the surface more 
engorged and reddened, and the greasy sweat-like exudation more 
abundant. 

The symptoms described above may begin either at the scalp or in 
one of the other regions named as the special sites of the disease, 
and spread thence, as from the scalp, over the adjacent parts. 
In extreme cases there are large portions of the body involved, 
for example, the greater part of the trunk and head ; but, as a rule, 
it is chiefly over those regions of the body where the sebaceous glands 
are largest and most abundant that the symptoms are most clearly 
manifested, that is, over the upper segment of the body. When 
there are reddish-yellow, roundish plaques of this disease over the 
sternum and shoulders, confluent or partially so, with a retiform ar- 
rangement and distinct contours, the disease is nothing more than 
the familiar seborrhcea trunci described on another page. Excep- 
tional forms are those in which reddish papules, isolated or confluent, 
appear over the forehead, nose, and cheeks, a species of acne in point 
of fact, which should be considered only with other acneiform affec- 
tions. The disorder may linger about the verge of the moustache or 
other parts of the beard, showing its grease and scales, even at a dis- 
tance from the line of the hairs, with an ill-defined, reddened surface 
beneath them. The same occurs about the line of the eye-brows ; 
and the disorder not rarely affects, to a very marked degree, the 
lining of the external conduit of the ear, blocking it with crusts, in- 
terfering seriously with audition, and even in cases resulting in grave 
impairment of hearing in consequence of changes induced in the 
drum. The dorsal surface of the hands and fingers may be involved, 
and also the palms, where pea-sized and larger macules become 
covered with scales, irregularly distributed over the surface. 

It will be seen from what precedes that the disorder (if such it can 
be called) is one which is described in all its features under other 
titles. It includes the symptoms of certain seborrhoeas of the scalp 
and non-hairy regions, various forms of alopecia, and not a few of 
the conditions which the French have grouped together under their 
title, pityriasis rubra pilaris. 

While it is true of diseases of the skin as of the other organs of 
the body, that they do not always present themselves in the severely 



808 DISEASES OF THE SKIN. 

classical limits of scientific analysis, and are often commingled in con- 
fusing relations, it is of enormous importance to the student, in order to 
insure against remediless confusion, that these scientific groups be 
clearly and rigidly separated in the mind. Such terms therefore as 
"eczema seborrho'icum," " lichen-psoriasis," and "syphilitic eczema," 
are in general to be avoided. 

Tuberculous Eczema of Nurslings, so called, is a term which 
has been applied to eczematoid eruptions about the mucous orifices of 
the eyes, nose, mouth, and ears, occasioned and sustained by morbid 
conditions of, and serous discharges from, those parts (otorrhoea, 
rhinitis, phlyctenular keratitis, etc.), and accompanied by oedema, 
vesiculation, and enlargement of lymphatic glands. They are charac- 
terized by rebelliousness to treatment and chronicity of course. This 
disorder is improperly named, since tubercle bacilli have not been 
recognized in its lesions ; and because the symptoms above enu- 
merated may all be present when there is simply systemic nutritive 
failure and when no tuberculosis of other organs is present. 

Eczema Diabeticorum (Fr., Diabetides). — A singularly well- 
defined eczema is to be recognized about the genital organs of both 
sexes, but more particularly of women, accompanied by the most 
atrocious pruritus, excoriations produced by scratching, and enormous 
tumefaction of the genito-anal and surrounding integument. The 
local symptoms are chiefly those of eczema erythematosum, the sur- 
face being, as a rule, destitute of either vesicles or pustules. There 
is often a profuse serous discharge, considerable infiltration, and the 
production of inflammatory nodules over the engorged surface. 

These cases fall within three categories. In the first and rarest 
the patient has saccharine diabetes of long standing, and the parts are 
simply irritated by the passage over them of urine charged with 
sugar. In the second and commoner form, there is a temporary 
glycosuria, either produced by the local eczema or indirectly resulting 
from the latter, and yet due to transitory causes, since both the eczema 
and the saccharine urine disappear with relative rapidity when the 
local treatment is combined with the dietary appropriate for the 
diabetic. In a last group the sugar fungus (torula cerevisiw) finds a 
nidus in the skin. 

Eczema Parasiticum. — Under this title is included a large 
number of cases whose exact relations to the recognized types of the 
disease are still indeterminate. It is well known, for example, that 
the surface of the human body in health is the site of an enormous 
number of differing parasites which are, for the most, harmless or 
effective as agents of disease only under certain specially favorable 
conditions of the body. Cultivation experiments with the flora 
found on the eczematous skin have revealed a large number of para- 
sites, for the most part of vegetable origin, which together, if not 
singly, may be effective in producing some of its distinctive features. 



ECZEMA. 309 

According to Unna, eczema is in these cases a chronic parasitic 
catarrh. 

Eczema Marginatum is that form in which the parasite produc- 
tive of ringworm is the effective cause of the disorder, and, accord- 
ing to the author last quoted, eczema seborrhoicum is to be included 
in the same class. 

Etiology. — Eczema is a disease of both sexes and of all ages. 
Tendencies to all disorders of the body may be inherited, but eczema, 
as such, is not an inherited disease. It is noted elsewhere that 
eczema, in certain cases, is due to parasites ; but it should, neverthe- 
less, for the majority of cases, be classed with non-contagious affec- 
tions. 

In many cases no cause of eczema can be discovered beyoud those 
which operate exclusively within the skin- organ and are proper to 
itself. These are necessarily obscure, and will remain so until we 
are in possession of far more knowledge as to the complex and 
inscrutably delicate processes by which innervation, nutrition, and 
new formation of the living matter of the skin are both conserved 
and impaired. The autonomy of the integument must be conceded 
to the extent recognized in other organs of the body. There are 
diseases of the liver which are neither referred to the blood, the 
nerves, nor the action of poisons. There are diseases of the heart 
which can be induced by neither rheumatism nor syphilis. When 
the etiology of the disorders of all the viscera is perfected, that of the 
skin displaying the lesions of eczema will be assuredly more distinct. 

These remarks are justified by clinical facts. Eczematous affec- 
tions occur in the persons of individuals who are in every respect 
superb examples of good health, where the most thorough and careful 
examination fails to reveal for the disorder either an external or in- 
ternal cause. Eczema occurs also in persons who are affected with 
every form of bodily ailment ; those suffering from acute and chronic 
disorders of every viscus and system of the body ; and even those 
affected with other disorders of the skin. This is only what a study 
of established facts would suggest, having in view the probable pro- 
portion of eczematous attacks in every thousand individuals. Such 
coincidences would, however, scarcely furnish a satisfactory etiological 
basis for the disease, unless a certain degree of constancy between 
eczema and these disorders could be established. Thus eczema is 
often seen in patients affected with rheumatism, gout, dyspepsia, 
malaria, obstinate constipation, anemia, scrofula, and pulmonary dis- 
orders, a list of affections exhibiting surely very wide pathological 
differences. Yet he would prove to be a physician of exceedingly 
limited experience who could not select from patients under his own 
observation twenty individuals affected with any one of the diseases 
named, no single person of the entire number having ever exhibited 
symptoms of eczema. If figures alone were to decide the question, 
these, and a larger list of maladies which have been named in similar 



310 DISEASES OF THE SKIN. 

connection, would be excluded in the study of the etiology of the 
disease. 

As predisposing causes, those operating by inducing systemic 
debility, many if not all the diseases named above, may be effective. 
In this way, chlorosis, albuminuria, diabetes, tuberculosis, struma, 
gout, rheumatism, uterine disease, dyspepsia, hepatic disease, consti- 
pation, and other gastro-intestinal disorders may lay the foundation 
for a persistent eczematous attack. In a similar way it is possible 
that a predisposition to this disease may be inherited, but, as distin- 
guished from all the diseases known to be transmitted by heredity, 
no child was ever born into the world with an eczema. 

Eczema seems, in exceptional cases, to bear some relation to spas- 
modic asthma, sometimes coexisting with that disease in one person, 
or its attacks alternating quite regularly with asthmatic paroxysms. 
This may be due to the exquisite sensitiveness of the skin, mucous 
membranes, and nervous system exhibited in some patients. 

The so-called internal causes of eczema must be, for reasons given 
above, considered for the most part as either coincidences or condi- 
tions which favor the development of diseases in general, eczema not 
excepted. By interference either with innervation, nutrition, devel- 
opment, excretion, or the performance of the important functions of 
the body, as well as by reflex irritation of the surface, they operate 
by inviting, aggravating, or prolonging an eczematous attack. 
Among these may be named : not merely the diseases enumerated 
above, but also as physiological states, preguancy, lactation, and den- 
tition ; as associated with the habits of life, occupations necessitating 
inordinate fatigue of body or mind, especially with the exclusion of 
sunlight ; and lastly, as originating in the irritative action upon the 
mucous surfaces, of substances foreign to the body, dietary and 
medicinal articles capable of exciting cutaneous rashes, intestinal 
parasites, and instruments inserted and fluid injected into the mucous 
canals, as, for example, the male urethra. 

This much premised, it should be added that every phase of 
eczema can be artificially produced upon the surface of the skin by 
the action of external irritants. Several authors, notably those of 
French nationality, take exception to this view, claiming that the 
induced disease in such instances is an artificial dermatitis, but they 
fail to point out the distinctive objective differences between such 
dermatitis and eczema. They content themselves with observing the 
subsequent evolution of the malady, and pronounce that to be an 
eczema which fails to respond promptly to treatment, and that a 
dermatitis which is capable of speedy relief. The climax of such 
absurdity is reached when they are shown obstinate cases of eczema 
of artificial origin, and the response is, that the induced dermatitis 
gave rise to an eczema in a predisposed subject. 

One step further and one is in position to estimate the approxi- 
mate value of the etiological factors in eczema. The large majority 
of all generally recognized and externally operating causes of the 
complaint fail to have such an effect in the mass of individuals. 



ECZEMA. 311 

Whether any one of them be necessarily followed by the disease is 
open to some question. Even the poison ivy, a fertile source of the 
disorder in susceptible individuals, will fail to influence others. The 
late and eminent Professor Boeck, of Christiania, when he last visited 
America rubbed the tender leaves of this plant over his hands and 
face in repeated efforts to produce the disease in his own person, and 
utterly failed of the desired end. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration, they can all be 
referred to either : solar light and heat ; contact with foreign bodies 
in various vaporous, fluid, or solid states ; toxic agencies of a widely 
different nature ; traumatisms in varying degrees ; and the action of 
parasites. Mauy of these co-operate ; some iuclude others ; and some 
become effective by aggravatiug a disease which others have engen- 
dered. The reader is referred to the chapter on general etiology for 
fuller consideration of this subject. It will be sufficient to note here 
that acids, alkalies, antimonial and mercurial compounds, mustard, 
sulphur, castor oil, capsicum, arnica, turpentine, chloroform, ether, 
alcohol, and a long list of other medicaments are capable of produc- 
ing eczema when applied to the skin externally. The same is true 
of articles manipulated in mauy of the trades — those, for example, 
handled by the grocer, the baker, the confectioner, the seamstress, 
the ink-mauufacturer, the mason, the cook, the gardener, the laun- 
dress, the painter, the dyer, the printer, the tobacconist, and the 
chemist. Then, too, the eczema of the person exposed to severe 
cold, or intense solar light and heat, aided by reflection from the 
water, or even by excessive artificial heat, as the fire of a furnace, 
illustrates the action of other causes named. Pressure and friction 
effects are exhibited in the eczema produced by contact with gaiters, 
cuffs, trusses, saddles, crutches, and corsets. 

Scratching is a fruitful cause of eczema when the skin is affected 
with pruritus as a distinct disease, or as a symptom of other cutaneous 
disorders. Thus it is efficient in urticaria, scabies, and the prurigo 
of Hebra ; in the skin bitten by lice, insects, bed-bugs, and fleas 
(which even without such interference are capable in many cases of 
inducing the disorder) ; and in the lower extremities, where the skin 
is distended by varicose veins. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema, whether it proceeds from the 
sudoriparous glands in an excessive exudation of sweat which is not 
duly removed by ablution, or be applied externally as a fluid in ex- 
cessively cold or hot temperatures, or in the vapors of the popular 
Turkish and Russian baths, or yet again be rendered irritating by 
saline or other constituents. 

The external sources of eczematous trouble named above should 
be regarded simply as suggestive illustrations. It should be borne 
in mind that every contact with the external world, sufficiently severe 
or prolonged to awaken the resentment of the healthy skin may be 
followed by the protest of the latter in the shape of an eczema ; 



312 



DISEASES OF THE SKIN. 



and the same may be true when even the most trivial external acci- 
dents occur to the sensitive skin of certain individuals particularly 
prone to the disease. 

The forms of eczema due to parasites are described under that title. 
Some of the latter are derived from the animal and some from the 
vegetable kingdom. 

Pathology. — The pathological changes in eczema are those of in- 
flammation of the skin, varying somewhat with the acuteness or 
chronicity of the process, and the character and career of the exudate 
furnished in each expression of the disease. In all cases there is, 
first, a circumscribed or diffused hyperemia of the affected part. 



Fig 47. 




Chronic eczema — vertical section of the skin of the forearm, a, epidermis ; 6. thickened 
rete ; c, hyper-pigmented layer of rete ; d, enlarged papillae ; e, atrophied sebaceous gland ; 
f , atrophied hair- follicle ; g, infiltrated coriuro. (After Kaposi.) 

This results from a series of more or less rhythmical and alternate 
dilatations and contractions of the vascular capillaries, the apogee of 
which is persistent vascular distention, blood-stasis, and the condition 
generally recognized as engorgement of the affected parts. This 
engorgement becomes visible to the eye in various shades of increased 
redness. There occurs an exudation by which a material in various 
degrees of fluid or solid consistency is added to the tissues. This 
process is also coarsely appreciable, either by the free ooze of serum 
from the surface, or by the imprisonment of such exuded fluid in the 
chambers of the vesicles which it produces, or by an increased thicken- 
ing of the various constituents of the skin, perceptible when these 



ECZEMA. 313 

are pinched up between the finger and thumb, or lastly^ by the 
appearance of various solid or semi-solid projections concerning the 
skin proper, or secondarily, its glandular appendages, which visibly 
spring from the involved area. Thus are explained the various ery- 
thematous, vesicular, pustular, and papular manifestations of eczema. 

A history of the many doctrines which have been held regarding 
the part played in these phenomena by the bloodvessels, the nerves, 
and the tissues would simply exhibit the several steps which have 
been taken in arriving at the facts now demonstrable. The researches 
of Heitzmann serve to throw light upon this inflammatory process 
in the skin in a highly satisfactory way. 

As to the part played by the epithelium, Heitzmann 1 shows that 
the initial step of the inflammation is declared by an increase of the 
living matter, both within and between the protoplasmic bodies ; the 
former produces a coarse granulation of the epithelia due to increase 
of living matter. This increase is evidently due to augmented afflux 
of nutritive material in the stage of hyperemia. It is declared at 
the points of intersection of the protoplasmic network (the formerly 
so-called granules) by their enlargement, and by the shining and 
solid condition of that part of the network called the nucleus. The 
increase of living matter between the protoplasmic bodies is declared 
in a thickening of the threads traversing the cement substance. 
Every particle of the living matter, either within or between the 
epithelia, is capable of producing a new formation of epithelial ele- 
ments. Thus is explained the part played by the epithelium in the 
thickening of the skin, the production of scales in squamous eczema, etc. 

In connective tissue, the first manifestation of the inflammatory 
process is the dissolution of the basis-substance, and reappearance of 
the protoplasmic condition ; by this process, and the new formation 
of medullary elements which may start from any particle of living 
matter, the inflammatory infiltration is established. The sum total 
of the inflammatory elements which remain united with each other 
by means of delicate offshoots represents an embryonal or medullary 
tissue. In the case of erythematous eczema, the new formation of 
medullary elements is scanty, and resolution is accomplished by 
reformation of the basis substance. 

In papular eczema the papillae of the skin are enlarged in all 
diameters, partly owing to a dilatation and enlargement of their capil- 
lary bloodvessels, and partly to the peculiar connective tissue changes 
already described. Plastic formative inflammation may be accom- 
panied by the accumulation of a larger amount of serous or albu- 
minous exudation in the epithelial layer, as in vesicular eczema. 

Suppuration in the epithelial layer of the rete mucosum is pro- 
duced by the accumulation of an albuminous or fibrinous exudate, 
in consequence of which a number of epithelia are destroyed, and by 
a new formation of pus corpuscles from the living matter of the 
epithelial element themselves. Epithelial suppuration of this sort 

1 Transactions Amer. Derm. Association, Fourth Annual Meeting. 



314 DISEASES OF THE SKIN. 

is not followed by a cicatrix. This is the pathology of eczema pus- 
tulosum and eczema madidans. 

The elevation of the temperature in the inflamed skin is somewhat 
proportioned to the rapidity of the process. In acute eczema, such 
elevation may exceed 105.5° F. (41° C), while in chronic eczema it 
can scarcely be appreciated. 

The fluid exuded iu eczema, whether taking part in tumefaction 
of any portion of the skin, as in vesiculation, or in a free discharge 
from the surface, is always identical. It is a yellowish- white, sticky 
and syrupy liquid, feebly alkaline in its reaction, depositing albumin 
in abundance when treated by heat and nitric acid, and exhibiting 
the characteristic features of the serum of the blood under the micro- 
scope. Exposed to the air, it desiccates in light yellowish to brownish, 
friable crusts, which resemble honey or gum. 

Increase in the pigment particles distributed to the epithelia of the 
rete is characteristic of the chronic forms of eczema, and more espe- 
cially of those where the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. This 
is true, however, of all diseases accompanied by an augmented afflux 
of blood to any part of the body, as, for example, over the surfaces 
of joints to which for many years stimulating embrocations have 
been applied. 

Diagnosis. — Eczema is, in its manifestations, such a protean disease 
and is, moreover, of such frequent occurrence, that it is necessary to 
establish a differential diagnosis between it and a large number of 
other cutaneous disorders. The more important of these are named 
below in alphabetical order for convenience of reference, the distinc- 
tive differences of each being briefly appended. It must be remem- 
bered, however, that the identity and characteristics of eczema are 
made clear only after a close study of all its features ; and that is the 
surest basis for an accurate diagnosis in every case : 

Acne. — Acne occurs chiefly on the face, neck, and back of the 
trunk, and its pustular forms might be mistaken for eczema of the 
same localities. But pustular acne is usually accompanied by a 
deeper-seated infiltration than the similar lesions of eczema ; and this 
infiltration is also generally limited to the sebaceous glands or peri- 
glandular tissue. In eczema the itching is often severe, while in 
acne the subjective sensations are those of heat or burning ; come- 
dones intermingled with the pustules of acne will aid in distinguish- 
ing the two. 

Erythematous eczema of the face is to be distinguished from Acne 
Rosacea by the more generalized infiltration of the former, its pro- 
duction of itching, and its greater diffusion over the face ; while 
acne rosacea is more often limited to the cheeks, nose, brow, and 
the region adjacent to these parts. The patch of erythematous 
eczema is " hot ;" that of acne rosacea " cold" to the touch. The 
former is seen in infancy ; the latter is rare in that period of life. 
Acne rosacea is also in many cases readily distinguished by the de- 



ECZEMA. 315 

velopment of visible bloodvessels in the skin of the cheeks or nasal 
region. Lastly, in erythematous eczema, the lids are apt to suffer, 
while in acne rosocea this is the exception. In severe forms of acne, 
the sub-epidermic pus formation and the resulting scar will prove 
significant. 

Dermatitis. — Dermatitis, of artificial origin, is to be distinguished 
from idiopathic eczema rather by its history thau by special differ- 
ences in the appearance or evolution of lesions. In many cases the 
two affections are indistinguishable. A history of traumatism or of 
the external application of irritant or toxic articles, will often serve 
to distinguish the two. When the dermatitis has been produced by 
an externally applied irritant, the resulting inflammation of the skin 
will often exactly outline the area of contact. Dermatitis of artifi- 
ficial production is usually sudden in its onset, the date of which 
will nearly correspond with the time of the operation of the exciting 
cause. The subsidence of the symptoms after the withdrawal of the 
cause will also point to the nature of the affection. Eczema is also 
much more capricious in its distribution and career. 

Erysipelas. — Erysipelas is generally accompanied by febrile 
symptoms, and in many cases bullae appear. The affected surface is 
reddened, much more swollen than in eczema, and exhibits besides a 
characteristic shining appearance, which is always absent in ery- 
thematous eczema. The line of demarcation between the affected and 
unaffected portions of the skin is usually distinctly defined in ery- 
sipelas, ill defined in eczema. Erysipelas spreads from one point to 
another with a rapidity which is never noticed in eczema, the latter 
disease, moreover, exhibiting under a glass its minute papules or 
vesicles. In eczema also, when occurring upon the face in the ery- 
thematous form, the scalp is usually spared, while erysipelas tends 
to invade the scalp and the regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperaemia only, by the presence of an 
inflammatory process. The erythema simplex which advances to 
exudation, at once transgresses the artificial line of distinction between 
the purely congestive and purely exudative disorders. It must there- 
fore be remembered that many eczemas begin as erythemata, and that, 
clinically, the latter may represent but a stage in the morbid process. 
The discharge in erythema intertrigo results from imprisoned or 
chemically altered sweat, and will not stiffen linen, as does the serous 
exudation of vesicular eczema, for example. Erythema multiforme, 
an affection really on the border line between the two pathological 
classes here sought to be distinguished, will be recognized by the 
absence of severe itching, and the recurrence of the disorder at certain 
special seasons of the year ; while E. papulosum, E. tuberosum, and 
E. nodosum, display solid elevations of the surface much exceeding 
in size the minute lesions of papular eczema. 



316 DISEASES OF THE SKIN. 

Herpes. — Eczema is, in the minds of many, so associated with the 
occurrence of a vesicle, that other vesicular disorders are apt to be 
confouuded with it. But in herpes febrilis the vesicles are usually- 
grouped about the mucous outlets of the body, and when actually 
uuder observation they exceed in size the minute and transitory 
lesions of vesicular eczema. In herpes zoster, with the limitation 
of the eruption to one side of the body, there is also a history 
of precedeut neuralgic pain. The subjective sensation is a decided 
burning rather than itching, and there is a possibility of the subse- 
quent production of scars. 

Impetigo and Impetigo Contagiosa. — In these forms of dis- 
ease the pustular lesions are usually isolated, do not spring from an 
infiltrated surface where other lesions may be visible, and are unac- 
companied by the intense pruritus which is characteristic of eczema. 
The pustules, moreover, are larger, and the resulting crusts, as a rule, 
bulkier and darker colored than in eczema. Again, in pustular 
eczema the cutaneous affection usually occurs in one or more patches, 
while in impetigo a dozen or more isolated pustules may be irregularly 
scattered upon the entire surface of the body. In the contagious form 
of impetigo, there may be a history of the extension of the disease 
from one member of a family to another. 

Lichen Planus. — In this disorder the papules very rarely be- 
come vesicular as in eczema ; while those of the last-named disease 
never assume in any stage the peculiar sepia-tinted hue of the similar 
lesions of lichen planus. The latter, moreover, are often umbilicated, 
are chronic in development, frequently symmetrical in disposition, 
and are scaly at the flattened summit. 

Lichen Kuber. — Here the dull red, non-excoriated papules, 
covered with minute scales, unattended by severe itching, could 
scarcely be mistaken for the vivid, angry, and scratched papules of 
eczema, which, moreover, are often accompanied by secretion from 
the surface. When the scales covering patches of coalesced papules 
in lichen ruber are removed, the orifices of dilated hair-follicles be- 
come visible. This is never true of papular eczema. But the im- 
portant symptoms of a grave disease in lichen ruber, such as maras- 
mus and the indications of a fatal termination, will not fail to attract 
attention. 

Lupus Erythematosus. — Lupus erythematosus greatly resem- 
bles certain forms of squamous eczema. The greater chronicity of 
lupus ; the firm attachment of the scales ; the symmetrical distribu- 
tion of certain patches upon the face ; the association of some forms 
of the disease with the sebaceous glands ; the definite border of each 
involved area; and. above all, the discovery of the cicatrix where it 
has existed, will sufficiently distinguish the disorder. In eczema, 
there is usually itching, often vesiculation, more rapid extension of 
the borders of a single patch, and scales much more loosely attached, 



ECZEMA. 317 

than in erythematous lupus, which are never provided as in the latter 
disease with stalactitiform plugs on the iuferior surface. 

Lupus Vulgaris. — Lupus vulgaris is readily distinguished from 
eczema by its more chronic career, its larger papules aud tubercles of 
dark reddish -brown hue, aud by every one of its destructive pro- 
cesses, none of which is ever recognized in eczema. 

Pediculosis. — As eczema is often induced by lice upon the head, 
pubes, or clothing, it is always necessary to exclude the operation of 
such causes both for diagnostic and therapeutic purposes. Eczema, 
limited to the pubic region or existing there, and elsewhere only 
about the axillae, should suggest careful examination of the skin and 
hairs for the discovery of the crab louse. As for the pediculus cor- 
poris, it should be the rule of the physician, invariable and never to 
be forgotten (whatever the social position or refinement of his patient), 
to search for evidence of the parasite upon the under surface of the 
clothing worn next to the skin, at the instant of its removal and 
while the patient supposes him to be busied with the inspection of 
the cutaneous lesions. The excoriations produced by scratching 
wounds inflicted by body lice are usually out of all proportion to the 
amount of skin disease present ; and this is the most significant of 
all symptoms next to the discovery of the corpus delicti. Head lice 
may precede or follow eczema of the scalp, but either they or their 
ova (nits), clinging in numbers to the hairs, will be visible to him 
who looks carefully for them. 

Pemphigus and Pityriasis Eubra. — The large isolated bullae 
of pemphigus vulgaris are never seen in eczema. In pemphigus 
foliaceus the lesions are succeeded by the formation of pastry-like 
crusts, serous exudation, considerable soreness, and the eventual 
production of an extensive aud usually fatal exfoliative dermatitis. 
Marasmus more or less rapidly ensues, while, as a rule, itching 
and infiltration are not present. The disease known as pityriasis 
rubra is equally rare and fatal ; and, though unattended with the 
production of bullae, is characterized by an equally abundant epidermic 
exfoliation ; itching and infiltration being either entirely wanting or of 
insignificance in comparison with the other symptoms present. The 
scales too are papery, large, and thin ; there is no vesiculation and 
moisture, and little, if any, infiltration of the skin. The integument 
is, moreover, of a uniformly reddish hue. Both pemphigus foliaceus 
and pityriasis rubra are particularly liable to be complicated with 
chills or uncontrollable diarrhoea. Without question, many of the 
reported cases of so-called pityriasis rubra are instances of squamous 
eczema. Here the localization of the disease to one or more patches 
upon the body, the severe itching, and the distinct infiltration of the 
patch, will point to the eczematous character of the disease. Obser- 
vation of such patients will finally convince the observer, in many 
cases, that there is occasional weeping from the surface. 



318 DISEASES OF THE SKIN. 

Pitykiasis Rubra Pilaris. — Often this resembles in a high 
degree the squamous forms of eczema, and it may indeed be con- 
fused with the latter in the description given by some French authors. 
In general there is not found in eczema the characteristic lichenoid 
papules, formed about the hair follicles, with their hyperkeratinized 
cap sheathing the follicular orifice, over the extremities and espe- 
cially over the dorsal aspect of the fingers. In eczema there are 
usually distinct marks of scratching which may be wholly wanting 
in pityriasis rubra pilaris; and the latter has distinctly a more 
chronic course in the most of cases. 

Prurigo and Pruritus. — In the prurigo of Hebra, a disease 
exceedingly rare in this country, there are infiltration, intense itching, 
and numerous minute papules. But the disease usually occurs within 
a year or two after birth, and lasts for a lifetime, extending generally 
over the greater part of the body, sparing only the palms and soles 
(which eczema does not), and is accompanied by inguinal adenopathy. 
In pruritus, often confounded with prurigo, there is itching without 
disease of the skin save that induced by the nails to relieve the sen- 
sation. Hence, pruritus without scratching will not reveal a cutane- 
ous disease; while the same disorder with scratching will exhibit 
either excoriations, or an eczema induced by the attacks made upon 
the skin. The last is, however, rarely noted. The distinction will 
be clear when it is remembered, first, that pruritus is usually of a 
paroxysmal character, worse regularly at certain hours or seasons ; 
second, that pruritus not originating in a cutaneous lesion, but in- 
directly producing the latter by the medium of the nails, never ex- 
hibits as much cutaneous excoriation as the skin bitten by lice or 
attacked with eczema. The impressive features here are always 
the disproportion between the complaint of the patient and the visi- 
ble symptoms, and the vast preponderance of all lesions, when the 
skin has been scratched, in those regions of the body most accessible 
to the hands, such as the anterior faces of the limbs, the genital 
region, lower belly, etc. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 
Variations from type in the direction from one to the other furnish 
many obscure cases. 

The following are the chief diagnostic points in psoriasis : sharp 
definition of contour of patch ; abundance and lustrous hue of scales; 
absence of moisture ; vascularity of tissue beneath the scales ; sites 
of election on posterior aspect of trunk and extensor surfaces of 
limbs ; chronicity in course ; uniformity of lesions ; and usually 
absence of itching. In eczema : there is an ill-defined contour ; 
usually scanty scales not having a nacreous hue ; a preference for the 
flexor surfaces of the extremities, though the disease may occur in 
any portion of the body ; generally, at some period in its course, a 
history of moisture ; polymorphism, as regards lesions ; and a marked 
intensity of subjective sensations. Upon the scalp, psoriasis is par- 



ECZEMA. 319 

ticularly apt to extend beyond the hairy border in a fillet stretching 
across the upper portion of the forehead and thence irregularly down 
in front of the ears ; while eczema of the face, when the scalp is also 
invaded, departs boldly from the hairy parts to the lower limits of 
the forehead, lips, nose, cheeks, or chin, regions which are rela- 
tively spared by psoriasis. Finally, the two diseases, in doubtful 
cases, will generally be distinguished by carefully searching the 
entire surface of the body, upon some part of which, in psoriasis, 
there will usually be discovered a tell-tale patch of typical appear- 
ance. 

Scabies. — Scabies is really an artificial eczema induced by the 
incursions of the acarus scabiei, and its lesions are thus those of 
eczema. In scabies, however, the pruritus is intense and the several 
papules, vesicles (these much less closely set than in eczema), and 
pustules are more likely to be coincident than successive, exhibiting 
thus the multiformity characteristic of the disorder when produced 
by the parasite. The discovery of the presence of the latter, especi- 
ally if there be a history of contagion and the localization of the 
disease in its sites of preference, will at once determine the diagnosis. 
Scabies never attacks the scalp. Its sites of preference are, in both 
sexes, the fingers, hands, wrists, and axillae ; in women, the breast 
and the nipple ; in men, the penis ; and, in children, the buttocks. 
The presence of the acarian furrow, if the disease has existed for 
some time, and the appearance of minute blackish dots or points 
upon or about the lesions, usually suffice to establish the real nature 
of the disease. 

Scarlatina. — This disease could only be confounded with cer- 
tain of the varieties of eczema exhibiting an erythematous type. 
In scarlet fever, however, the elevation of temperature, the appear- 
ance of the tongue and fauces, and frequently the history of conta- 
gion, serve to distinguish the disease. The peculiar "boiled lobster " 
appearance of the skin, and its symmetrical distribution over the 
surface of the body, with gradual extension from the head and trunk 
to the lower extremities, are never seen in eczema. The finger-nail 
drawn across the skin of the patient affected with scarlet fever is usually 
followed by the appearance of a whitish line corresponding with the 
impression made with the nail, which is highly characteristic of the 
eruption. Lastly, a generalized eruption of eczema will never disap- 
pear with the rapidity of the scarlatinal rash. 

Seboeehcea. — Seborrhoea and eczema may coexist, either disease 
preceding the other. Typical forms of each are readily distin- 
guished. In eczema there is infiltration and much consequent 
itching ; in seborrhoea, neither. The scales of seborrhoea are more 
voluminous, greasy, freely shed from the surface, and seated usually 
upon an integument of scarcely altered hue. In eczema the scales 
are dry, scanty, and more firmly attached to a usually hypersernic 



320 DISEASES OF THE SKIN. 

base. Seborrhoea of the hairy parts is generally symmetrically 
diffused ; eczema, though occurring with ill-defined contour, is rarely 
as symmetrical, usually more acute, and seldom followed by alopecia. 
Upon non-hairy portions of the body the same distinctions can be 
to a great extent observed. The crusts of eczema removed from the 
face generally disclose beneath them an oozing surface, while the 
under surface of these crusts never exhibits the stalactite-like pro- 
longations which pass from the under surface of seborrheic crusts 
into the patulous orifices of the excretory ducts of the sebaceous 
glands. In eczema seborrho'icum the features of both diseases are 
completely fused. 

Sycosis. — Both the so-called parasitic and the non-parasitic forms 
of sycosis are limited to the region of tiie beard, while eczema of 
the hairy portions of the face will usually be found to affect other 
parts. In eczema the itching is severe, the exudation spreads 
beyond the limits of the beard, and the discharge is characteristic, 
while in both forms of sycosis there is less oozing, and the subjective 
symptoms are trivial. The discovery of the parasite in the root 
or shaft of the hair will at once distinguish the hyphogenous forms of 
the disease. In sycosis, each pustule is perforated by a hair. Eczema 
limited to the region of the beard is even rarer than the two varie- 
ties of sycosis. The circumscribed indurations and tuberculations of 
the affection produced by the trichophyton, as well as the looseuing 
of the hairs in their follicles, constitute further distinctive differ- 
ences. 

Syphilis. — There can be no question that several syphilitic erup- 
tions resemble certain forms of eczema. In the eruptions due to 
syphilis, however, there is usually a history of infection ; of involve- 
ment of the glands and mucous surfaces ; of ulceration and cicatrices 
in advanced periods ; and, especially in the case of infants with an 
eczema-like eruption, a history of snuffles. It should always be 
remembered that the intense itching of eczema is characteristic of no 
one of the syphilides; and that the latter are remarkable for their 
tendency to occur with a circular or partially circular outline, and to 
be covered with bulky crusts of an offensive odor. A point partic- 
ularly worthy of note is suggested in the diagnosis of chronic eczema - 
tous affections. A syphilitic eruption limited for an equal period of 
time to one locality will often ulcerate or exhibit evidences of repair 
by scar tissue, no such lesions occurring in eczema. 

Syphilis of the palms and soles exhibits very distinctly limited 
outlines in the usually circular, circumscribed, and deeply infiltrated 
patches present, which are often symmetrical in development, or at 
least situated on both sides of the body, even if more fully developed 
upon one limb. Syphilitic pustules upon the scalp usually rise 
above well-defined ulcers. Syphilitic eruptions encircling the mouth 
in children are less angry-looking and formidable than severe eczema 
of the same region, being often made up of flattened papules, moist 



ECZEMA. 321 

or scaling, grouped in circles about the lips, with mucous patches at 
the angles. 

Tinea Circinata. — In ringworm there should be a history of 
contagion, microscopical discovery of the vegetable parasite, distinct 
contour of all separate patches, absence of marked subjective sensa- 
tious and of discharge. These are not symptoms of eczema. In 
ringworm of the scalp the hairs loosened in their follicles are usually 
either brittle or actually broken at a short distance from the scalp ; 
the scales are fine, dirty-white, and not torn from the surface by the 
finger-nails. In eczema the hairs are unaffected, and their extrac- 
tion from the follicles is productive of pain. 

In ringworm of the body the patches are distinctly circular ; more 
scaly or papular at periphery than centre; and, moreover, yield with 
exceeding promptness to the action of a parasiticide. Occurring about 
the thighs and ano-genital region, the disease may be complicated by 
eczema, but the characteristic "festooning" of the advancing border 
of the patch downward along the thigh, or upward over the pubes, 
will suggest a microscopical examination of the scales scraped from the 
surface. 

Tinea Favosa. — The cup-shaped, friable, yellowish crusts of 
favus in the scalp might be mistaken for the crusts of eczema of the 
same part; but here the exudation is slight ; there is little scratching, 
as in eczema, and hence no history of discharge. The odor, more- 
over, is characteristic. In case of uncertainty the microscope would 
indicate the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will 
reveal, beneath the epidermal plates, the spores and filaments of the 
vegetation which produces the ailment. From eczema it is easily 
distinguished by the absence of infiltration and of any history of 
inflammation ; by the very slight subjective sensation it produces ; by 
its peculiar fawn to chocolate-colored, slightly yellowish patches, with 
superficial furfuraceous desquamation, limited often to the anterior 
surface of the trunk, and readily removed by the action of a para- 
siticide. 

Urticaria. — In papular forms of this disease there may be a 
resemblance to eczema, the more marked as in children, especially, 
the two diseases may be intermingled. Characteristic wheals often 
occur by the side of eczematous patches, but as a rule, the urticarial 
lesions are less grouped, more generally disseminated, more evanes- 
cent, and much less scratched. 

Treatment. — It is proposed to describe here the treatment of eczema 
in general, reserving the consideration of the treatment of the forms 
occurring in particular localities of the body, to the pages which fol- 
low, and which are allotted especially to such local manifestations of 
the disease. 

21 



322 DISEASES OF THE SKIN. 

In acute eczema, as well as in many of the chronic forms of the 
disease, the first and most important requisite is that which is the 
simplest, and, perhaps, for that reason most commonly overlooked. 
This requisite is the exclusion of all sources of irritation. 

This completely secured, a large number of cases of the disease 
will proceed to a prompt recovery without any other treatment what- 
ever. Failing this, acute become chronic phases of the disease ; or 
there is a history of exacerbation, recurrence, or development of the 
disorder in new and perhaps distinct portions of the body, from 
reflex irritation Or augmentation of the sensitiveness of the skin to 
other sources of mischief. 

The exclusion of all sources of irritation necessitates, first, the 
withholding of all harmful internal medicaments. The number of 
patients presenting themselves for treatment of this disease, both in 
dispensaries, hospitals, and in private practice, who have aggravated 
their eczema by the medicaments they have swallowed, is incredibly 
large. Men and women, infants and adults, those who have been 
under the charge of physicians, and those who have purchased their 
drugs of the apothecary at the suggestion of the latter or of their 
friends, exhibit patches of acute or chronic eczema, intensely aggra- 
vated by the injudicious use of arsenic, iodide of potassium, bromide 
of potassium, Donovan's solution, and other harmful preparations 
contained in the various "blood -purifying" remedies sold in the 
shops. The practitioner whose patient comes to him after making 
trial of any such remedies, is strongly urged to set aside carefully the 
operation of such mischievous agents, and to watch the eruption care- 
fully, while their effect is vanishing. The result is often marvellous. 

The exclusion of all sources of irritation necessitates, in the second 
place, the avoidance of all injurious external contacts. Only gross 
ignorance or carelessness will overlook the fact that the inflamed 
skin, like the inflamed bone or the inflamed bladder, calls imperatively 
for rest. The prevalent idea is, however, that the patient with an 
inflamed joint retires to his couch or bed, while the patient with an 
eczema, if his disease be not so formidable as to necessitate temporary 
withdrawal from the pursuits of business or pleasure, belongs always 
to the peripatetic class. He consults a physician, swallows some 
medicine, anoints his eczematous skin with a salve, and returns to the 
vocation where his complaint was begotten, just as the man with a 
gonorrhoea will occasionally solace himself by embracing the source 
of his affliction. The baker goes to his baking ; the seamstress still 
pushes her weary needle through the dyed fabrics which first injured 
her hands ; the man with an eczema of the thigh walks the street 
with his trowser-leg rubbing the affected surface ; the nursing mother, 
with an eczema of the infra-mammary region, still suffers the milk, 
chemically altered in the heat of the summer, to flow over the tender 
surface of the breast ; or, in the case of her infant affected with 
eczema, stuffs the folds of a coarse diaper, half laundered or yet 
covered with the dejection from the bowels, between its thighs and 
over the anal region. 



ECZEMA. 323 

Next is involved the exclusion of all topical irritants in the hands 
of either physician or patient, designed to relieve the disorder, but 
having a precisely opposite effect. The number and variety of these 
articles are far from being commonly appreciated. Some are useful 
in advanced stages of the disorder, and harmful in its earlier periods. 
These are generally ordered by persons with a limited experience in 
diseases of the skin, and represent a long list of stimulating and 
astringent ointments. Some are employed in sheer ignorance of their 
effects, as, for example, crude petroleum, strong acids and alkalies, 
nitrate of silver, turpentine, and concentrated solutions of corrosive 
sublimate, intended to "burn out" the disease. 

Lastly, the exclusion of all sources of irritation necessitates saving 
the involved surface from the excoriations and other traumatisms 
produced by scratching, rubbing, and excessive washing of the eczem- 
atous skin. In the case of adults some restraint is here needed ; in 
the care of infants, this restraint may need to be enforced. 

This is the only proper treatment of eczema. That which is con- 
ducted without regard to this is unworthy of the name. The methods 
of treatment about to be described in detail are to be regarded as 
entirely auxiliary to the measures and precautions suggested above. 
If the latter could be perfectly secured in every case, no other treat- 
ment would be required. If the patient protests that he must con- 
tinue his vocation • the hands of the sugar-baker returning to their 
accustomed manipulations ; the feet of the busy pedestrian to the 
frictions incident to his daily locomotion, then let both physician and 
patient distinctly understand the facts of the case. The former 
advises the speediest method of relief; and the latter elects a slower 
and more uncertain course. In doing this he should be made to 
understand that the responsibility is, to that extent, to be borne by 
himself. What competent surgeon consents to be responsible for 
that fracture in which the extremities of the bone are daily subjected 
to movement on the part of the patient ! 

The great importance of rest and freedom from irritation of all 
sorts in eczema is well illustrated by two classes of cases. There is, 
first, the newly born infant whose sensitive skin responds early to 
its first harsh acquaintance with the outer world, by an explosion of 
eczema. But it is a fact of singular importance that no child is born 
into the world eczematous. If the nervous system were responsible 
for eczema, such a result might occur, for that system is not only 
capable in intra-uterine life, of producing club-foot and other deformi- 
ties, but also of influencing skin disorders. The author has reported 
a case of pigmentary moles at birth, and other observers have 
described similar facts where the lesions were distributed exactly in 
the situation of herpes zoster of the trunk, along the lines of the 
intercostal nerves. If the blood were responsible for eczema, the 
foetus surely might display its lesions, as it does those of syphilis. 
Animal poisons, as those of variola and scarlatina, do not spare the 
unborn child. Nor is it exempt from certain diseases of the integu- 
ment which are generally regarded as due solely to tissue changes, 



324 DISEASES OF THE SKIN. 

since newborn infants are occasionally seen affected with ichthyosis 
or sclerema neonatorum. 

Why is the tender skin of the foetus exempt from every form of 
eczema, and the tender skin of the infant accessible to each by such 
various approaches ? Will it be responded that the child has begun 
to respire and digest for itself ; that it has become suddenly strumous, 
dartrous, rheumic, arthritic, gouty, or herpetic ; that its standard of 
health is impaired ; that it is suffering from assimilative, nutritive, or 
nervous debility, or from any one of the other numberless perturba- 
tions to which eczema has been ascribed ? For him who can divest 
himself of all prejudice, there can be but a single answer to the 
question. The difference between the child uuborn and the child 
born is, as regards eczema, a difference solely of skin protection and 
skin exposure. The former enjoys what Dr. White has aptly termed 
a " prolonged, placid, subaqueous life." Anointed with unguent and 
immersed in its water-bath of grateful temperature, its skin cannot 
be fretted to produce an eczema. The child, abruptly and often 
rudely brought into contact with the outer world, may speedily 
exhibit the most formidable symptoms of the disease. 

The second class of cases to which reference is made, exhibit the 
reverse of this picture, and are best observed in hospital practice. 
Attacked with such severe symptoms of the disease as to justify admis- 
sion to these charities, eczematous patients, usually impoverished in 
their resources and often injured by exposure during severe bodily 
toil, rarely fail to improve greatly during the course of a few days, 
when no treatment of an active sort has been adopted. In the larger 
number of cases, while waiting to study the evolution of the disease, 
one is limited to the observation of its involution. The mere rest in 
bed in a recumbent position, with a proper regulation of the diet and 
exclusion of all sources of irritation, has here been sufficient to secure 
relief. 

If any apology be needed for the space devoted to this part of an 
exceedingly interesting subject, it must be based upon the great fre- 
quency of the disease ; the wide diffusion of erroneous doctrines 
respecting its nature and the method of its management, and the 
mischief resulting from the too common aggravation of the disease 
in its earliest manifestations. 

The dietary allowed the eczematous patient should be limited to 
the most digestible articles of food, and should exclude those known 
to be capable of exciting cutaneous irritation, a list of which is given 
in the chapter on urticaria. A moderate use of fresh meats at but one 
meal of the day, and cooked vegetables and fruits may be permitted ; 
but starchy articles in excess, hot breads and cakes, pastry, con- 
fectionery, cheese, pickles and pickled meats, cucumbers, cabbage 
both raw and cooked, parsnips, turnips, beans, oatmeal, cracked 
wheat, pease, celery, shell-fish, salted fish and meats, pork, and veal 
should be avoided. Milk, when not the source of constipation, may 
be drunk, but not during the meal hour. Coffee, tea, and cocoa, are 
in the doubtful list ; as these are positively injurious to some patients, 



ECZEMA. 325 

and apparently without effect in others. Tobacco should always be 
forbidden to male patients suffering from anything like a serious 
eczematous attack. Alcohol in every form is contra-indicated save 
in such conditions as debility or previous habitual use in moderation 
by persons of advanced years. In gouty cases the dietary should be 
of the strictest appropriate to that condition ; and in diabetic eczema 
the regimen proper in glycosuria is observed with great benefit in 
most cases. 

Internal treatment. — In the management of acute eczema, cooling 
draughts are useful ; and in all cases occurring in patients who are 
plethoric, who are constipated, or who suffer from other symptoms of 
imperfect excretion, aperients and cathartics are needed. Often a 
brisk mercurial purgative in the form of blue mass or the compound 
cathartic pill may be ordered at the outset. The rhubarb and soda 
mixture answers well in some cases. Podophyllin, irisin, and eupa- 
torium may be substituted for these, or the familiar combination of 
dux vomica, aloes, and belladonna. The saline cathartics, whether 
employed in medicinal formulae or in natural mineral waters, such as 
the Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are ex- 
ceedingly useful in the management of most cases. The following 
is a valuable combination often advised for cases where both iron 
and the sulphate of magnesium are indicated : 



R. Magnes sulphat. ^ij ; 64 

Acid, sulphur, dil. f^ij ; 8 

Ferri sulph. T) ss ; 

Sodii chlorid. ^j ; 4 

Cardamom, tinct. comp. f £j ; 4 

Aq. dest ad Oss ; 256 



60 



M. 

Filtra. Sig. A tablespoonful before breakfast in a tumblerful of cool or hot 
water. 

An excellent remedy for some cases is from fifteen to twenty drops 
of a fluid containing two parts of the fluid extract of cascara sagrada 
to one part of glycerin, the dose to be taken before breakfast in a 
small glassful of water. 

In some cases of renal derangement, the alkaline diuretics are 
indicated, such as the potassium acetate, carbonate, or citrate, adminis- 
tered with nitre, squills, caffein, or the benzoate of lithium in three 
to five grain (0.26-0.33) doses before meals (Piffard) ; and, in gouty 
cases, colchicum, Vichy water, etc. In patients suffering from acid 
dyspepsia, the liquor potassse, sodium bicarbonate, or ammonium 
carbonate maybe required. 

Aloes and iron, or aloes and ergot are often indicated in special 
cases. The late Dr. Tilbury Fox employed in cases where diuretics 
and alkalies were both indicated, a formula of this kind : 

&. Magnes. sulphat. ^ss; 16 

Magnes. carbonat. 3j ; 4 



Colchici. tinct. fgss; 2 

Menth. pip. ol. Ulij ; 

Aq. dest. f^vj; 192 



M. 



?ig. Two tablespoonfuls in a wineglassful of water every three or four hours. 



326 DISEASES OF THE SKIN. 

Cod-liver oil is indicated in all cases of struma and tuberculosis ; 
phosphate of lime in bronchitis ; steel in anaemia and chlorosis. 

In fleshy children affected with eczema capitis, calomel internally 
is a valuable remedy, one to two grains (0.06-0.133) of calomel, 
with two to three (0.13-0.26) of rhubarb rubbed up with five of 
calcined magnesia (0.33) may be giveu once in a day to an infant ; 
or one-twentieth of a grain (0.003) of calomel rubbed up with sugar 
of milk, may be given three times daily, for ten or twelve days. 
Van Harlingen advises small doses of the unspiced syrup of rhubarb, 
with or without magnesia, for the constipation of infants, or from 
one to three drachms (4.-12.) each of powdered rhubarb and the 
bicarbonate of sodium in four ounces (128.) of peppermint water, of 
which a teaspoonful may be administered two or three times daily. 
Quinine, strychnia, the syrup of the iodide of iron, and the wine of 
iron may also be used with advantage when indicated in these little 
patients. 

Beside the articles enumerated above may be named the following, 
which, after internal administration, have been reported as efficient 
in the hands of various authorities : Calx sulphurata and viola tri- 
color (Piffard) ; hyposulphite of sodium, ichthyol, chrysarobin, tar 
(for adults, two drops of purified pix liquida mixed with one-eighth 
part of rectified spirit, gradually increased — Anderson) ; carbolic 
acid, antimonial wine in five-minim doses, sulphur, turpentine, and 
hydrocotyle Asiatica. 

If the remarks which have preceded are justified by the clinical 
and pathological history of eczema, it follows that there is no con- 
stitutional treatment of the disease, save that which excludes all 
sources of irritation, a point to which attention has been already 
called. Once fully persuaded of this important truth, the physiciau 
should be capable of managing the complaint without mental bias in 
the direction of futile experimentation with drugs. 

The treatment of the patient, however, may be in one sense re- 
garded as the treatment of his disease, though a very large number 
of eczematous patients are, except as regards the skin, in conditions 
of health. Constitutional treatment, to meet any general conditions 
of ill health, should be, in short, such as is made familiar to the 
physician in his experience as a general practitioner of medicine. 

Mention has been made of but few of the disorders in the long 
list which may coexist with eczema. Some male patients with a 
gleet have an eczema of the thigh, kept up by the discharged secre- 
tion, which calls for treatment calculated in a very indirect manner 
to relieve also the cutaneous disorder. The same may be said of an- 
otitis externa with a purulent discharge, and of other local and con- 
stitutional ailments which the skilled physician should be competent 
to recognize and treat. Be it clearly understood the while, that all 
such treatment will not relieve an eczema. It simply places the 
patient in the most favorable condition for getting rid of local trouble. 
If one has had the opportunity of observing a large number of 
eczematous patients of every social class treated by internal medica- 



ECZEMA. 327 

tion of the character approved by those who still cling to a belief in 
the constitutional nature of the disease, he will see that the statements 
here made are based upon a conscientious study of this experience, 
and of the results of personal experiment in the same direction. He 
who desires to build solidly will not lay his corner-stone upon the 
shifting sands, where so many have been disappointed before him. 

Bearing in mind the fact that an eczema will occasionally vanish 
under even the worst mismanagement, the value of arsenic adminis- 
tered internally for its relief may be duly estimated. It is an un- 
certain remedy in all cutaneous diseases ; it is as uncertain in eczema, 
and has unquestionably aggravated as many cases as it has relieved. 
Its value in chronic and persistent forms of the disease is attested by 
men of distinguished reputation ; and upon such authority it may be 
conceded a position among the internal remedies for the malady of 
possible value. It is indeed not as remarkable that a few patients 
annually recover under its administration as that more do not attain 
the same fortunate end ; for it is the favorite dernier ressort in chronic 
scaling diseases of the skin with physicians of every grade of pro- 
fessional proficiency ; and, having in view the large percentage of 
eczematous cases with which they are confronted, it is a curiously 
suggestive fact that the position of arsenic in eczema is yet open to 
discussion. If arsenic, which certainly does possess au influence over 
the skin, cannot to-day be demonstrated to have therapeutic value in 
the large proportion of all cases of eczema, what can be said for the 
host of other drugs, too commonly employed for a similar purpose, 
which are inferior to arsenic in their cutaneous effects ? Sunlight, 
fresh air, suitable clothing, and due regime as to pleasure and busi- 
ness — these must be, for many patients, controlled by the physician. 
They do not cure eczema. They may do much to aid in its manage- 
ment ; they may do more, if neglected, to furnish sources of its 
aggravation. Crocker advocates counter irritation over the spine ; 
over the nape of the neck for eczemas of the upper segment of the 
body ; over the dorso-lumbar vertebrae for the lower parts. Jackson 
has used the ice-bag with advantage in the same wav. I can com- 
mend both plans from experience, as also counter-irritation of the 
corresponding part of the lateral half of the body for relief of an 
eczematous patch of long standing limited strictly to the other side. 

External Treatment. — The most soothing applications which can be 
made to the skin affected with acute eczema are, in various propor- 
tions and combinations, water, oil, dusting powders, and occasionally 
ointments. These will be separately considered, but two important 
circumstances must be remembered in their employment — first, that 
an article which will be grateful to the skin of one patient may prove 
irritating to another, the two being to all appearance similarly 
affected ; second, that where the surface is broken, from rupture of 
vesicles, excoriations, abrasions, or fissures, an applied fluid should 
be of greater specific gravity than the serum which is exuded, since 
otherwise endosmosis and exosmosis will occur, and the surface in 
consequence become more tumid and painful. 



328 DISEASES OF THE SKIN. 

Olive or other bland oils may be poured over the surface, applied 
upon folded pieces of lint, or used by inunction. Even these sub- 
stances are at times, however, the sources of irritation. They are 
made more soothing by combination with an equal part of liquor 
calcis, as in the Carron oil, constituted of equal parts of linseed oil 
and lime-water. For the linseed oil it is frequently advantageous to 
substitute cod-liver oil, palm oil, oil of sweet almonds, neat's foot oil, 
olive oil, or lard oil, flavored very slightly with bergamot or lavender 
to correct the disagreeable odor. In combination with equal parts of 
lime-water, one of these may be gently smeared over the surface, 
while a piece of lint, saturated with the same preparation, is also 
applied. In many cases the value of this dressing is greatly en- 
hanced by surrounding the whole with oiled silk or other impermea- 
ble tissue. 

The dusting powders, described in the chapters on General Thera- 
peutics and the Erythemata are available in many cases where the 
surface of the skin is, or is not, broken. These may be composed of 
lycopodium, magnesium, boric acid, bismuth, talc, the oxide of zinc, 
and camphor when an anti-pruritic effect is desired, in combination 
with finely powdered starch. The Anderson powder, the formula 
for which has been already given, is a useful combination of camphor, 
starch, and zinc. In their preparation it is of prime importance that 
they be made perfectly impalpable by sifting them carefully through 
silk bolting-cloth, as they are sources of irritation when they contain 
grain-like particles of untriturated material. The finely bolted 
" Oswego gloss starch," " corn starch farina," and rice flour, sold by 
the grocers, either singly or in combination with the other articles 
named, are generally accessible, and prepared at hand. It will often 
be of advantage, where exercise in the day is not prohibited, to 
employ one of the oily preparations during the night, which can be 
removed in the morning by a weak alkaline bath containing borax 
or the sodic bicarbonate, while the patient employs a dusting-powder 
in the daytime. This can be freely dusted over the surface, as also 
over the soft lint in contact with the eczematous skin, the stocking, 
glove, or suspensory bag being also well protected by the powder on 
its inner face. 

Water is of value in many cases when properly applied. Exces- 
sive washing of the eczematous surface is not only disagreeable to the 
patient, but irritating to the inflamed skin. Hot water, applied 
either as a lotion,' bath, fomentation, or by sponging, is frequently 
grateful and alleviates the itching. If employed at all, its use should 
be immediately followed, as soon as the part is carefully dried, by 
the other medicament selected for topical application, such as an oily 
or fatty substance, or a dusting-powder. 

Cold water is of service only when it can be continuously applied, 
as its intermittent employment is followed by a vivid reaction in the 
skin capillaries, whereby the itching is greatly increased. Thus are 
explained many of the nocturnal exacerbations of the disease, notably 
those occurring soon after the patient retires to his or her bed. A 



ECZEMA. 329 

cold bathing of the part before retiring has been followed by a tem- 
porary calmative effect, the blood being driven from the capillaries 
by the contraction of the tissues. The return of the circulating fluid 
in excess has then been aided by the warmth retained by the bed and 
the bed-clothing. The continuous application of cool or cold water 
requires a constant supply of the fluid from a reservoir of fixed 
temperature, and the exposure to the air of the part to which the 
dressing is applied. Thus evaporation is not checked ; and what is 
intended to be a continuous cold dressing is not transformed into a 
hot fomentation. 

Such fomentations are, however, frequently grateful to the patient's 
skin, and at times fulfil a good purpose. They are applied by dip- 
ping pieces of soft cloth in hot water, applying them neatly over the 
affected surface, and covering them with oiled silk, rubber cloth, or 
the " protective material " employed in antiseptic surgical dressings. 
Poultices of flaxseed, elm bark, or other bland materials operate in 
a similar manner, but are chiefly useful in softening crusts or other 
morbid concretions upon the surface. When too continuously or too 
frequently employed, they are productive of harm in their macerating 
and relaxing effect upon the skin, whereby its natural tonicity and 
instinct of self-repair (if such a term be permitted) are to a degree 
obtunded. They are hence but little used in eczema. The combined 
employment of water and fatty substauces is an exceedingly valuable 
method of soothing the eczematous skin, but, with the means accessi- 
ble in the private practice of many physicians, can rarely be secured. 
It certainly approximates most closely the sebaceous envelope and 
warm-water bath of foetal life. The eczematous skin is first anointed 
gently with a bland unguent, such as mutton tallow, suet, cold cream, 
or vaseline, and is then immersed in a bath of water kept continu- 
ously at the temperature of the blood. In the case of the lower 
extremities this is accomplished without great difficulty. Less per- 
fect than this is the anointing of the surface and the subsequent 
application of a warm fomentation, by strips of soft lint dipped in 
the water, superimposed with neatness, and subsequently covered 
with the protective gauze. Imbibition of fluids by the skin is pre- 
vented by its careful anointing ; and, when immersed in the water, 
the pressure is both uniform and gentle. 3 

Medicated water in baths and lotions plays an important part in 
the treatment of acute eczema. The liquor calcis with calomel, half 
a drachm to one drachm (2.-4.), aud pure glycerin or mucilage half 
an ounce (16.) to the pint (512.); the lead and opium wash ; glycerin 
one drachm (4.) to liquor plumbi subacetatis four ounces (128.); car- 
bolic acid one drachm (4), and glycerin two drachms (8.) to one 

1 A convenient method of makng the applications described above, is by the aid of spongio- 
piline. The eczematous surface is first anointed with a bland, neutral unguent, and then 
covered with a piece of spongiopiline, cut to the required size, sewn to a somewhat larger sheet 
of oiled silk or Lister protective, so that the edges may project on every side. The whole is 
retained in place bv a flannel or muslin bandage, to which the edges" of the impermeable 
material are attached by stitches. The snongiopiline is moistened with pure or medicated 
water, as desired, of a temperature nearlv that of the stomach, and may be re-moistened from 
time to time. 



330 DISEASES OF THE SKIN. 

pint (512.) of camphor or lime water ; a decoction of opium, made 
by boiling five to ten grains (0.33-0.66) of powdered opium in a 
pint (512.) of water, which is strained and rendered demulcent with 
mucilage ; sulphate of zinc ten to thirty grains (0.66-2) to the pint ; 
dilute hydrocyanic acid two drachms (8.) to the pint of water ; these 
and similar lotions, the ingredients of which are changed to suit the 
indications of each case, often serve to alleviate the itching, and in 
that proportion to diminish the intensity of the disease. Dr. White, 
of Boston, after bathing the parts for several minutes with the lotio 
nigra, dilute or in full strength, gently smears the surface with a 
small quantity of the oxide of zinc ointment, or in winter, four 
scruples (5.) of powdered zinc oxide to half an ounce (16.) each of 
cold cream and vaseline. Dr. Taylor, of New York, has suggested 
the following : 



. Liq. plumbi subacetat. 


gij; 


8 


Opii tinct. 


5 M ; 


64 


Camphorse tinct. 




32 


Glycerinse 


3y; 


64 



M. 

To this solution a greater astringent effect can be given by the 
addition of the subnitrate of bismuth, or oxide of zinc, half an ounce 
(16.) of either to the pint (512.) of the lotion. 

Dr. Duhring, of Philadelphia, has popularized the use of the 
fluid extract of grindelia robusta in the proportion of one part to 
four of water, as a lotion in eczema. Excellent lotions for soothing 
effect are also made by adding one to two drachms (4.-8.) of sodium 
bicarbonate to a quart of thin oatmeal gruel or marshmallow decoc- 
tion. Many patients will in this way secure relief which they can- 
not otherwise obtain. 

Other useful lotions contain finely levigated calamine, one to two 
ounces (32.-64.) to the pint of rose-water, with a small quantity of 
glycerin, and if the itching be severe, in addition half a drachm (2.) 
to one drachm (4.) of dilute hydrocyanic acid. Boric acid, one to 
two drachms (4.-8.) to the pint of an opiated wash; thymol, one 
part to one thousand ; and borax or the bicarbonate of sodium in the 
same proportion, containing besides an equal proportion of alcohol, 
spirits of camphor, or chloric ether, is also available. With any of 
these it is proper to moisten frequently the soft lint upon which they 
are applied, and this after ablution with hot, pure, or slightly medi- 
cated water, for the purpose of relieving the itching. 

Poultices made of crumbs of bread or of starch mixed with ice-cold 
lead-water ; and fomentations made by wetting cloths with chamo- 
mile water, and covering them with gutta-percha or other imper- 
meable tissue, are at times exceedingly grateful to the eczematous 
skin. 

From what has preceded, it will be clear that the chief end in the 
treatment of an acute eczema, is the relief of the subjective sensation 
of itching, and the exclusion of all irritants, the two being practically 
one. That which is not grateful to the skin of a patient thus com- 



ECZEMA. 331 

plaining, had better be, for the time at least, abandoned. So great 
is the difference between different patients as to the toleration by the 
skin of various topical remedies, that it is well as a rule, at the time 
of the first consultation, to order an alternative treatment, the one to 
be immediately substituted for the other, if such necessity arise. 
Especially is this true in cases where the epidermis is wounded, and 
where the patient can sometimes with comfort to himself exchange a 
dusting powder for a lead wash or a weak carbolized oil and lime- 
water lotion, while his eczema is tormenting him in different degrees 
at different hours of the day. 

The necessity for this relief is so imperious that at times it over- 
shadows all other symptoms of the disease. He who has never 
studied the case of a man or woman possessed with a furious impulse 
to relieve an intense eczematous pruritus has not yet completed an 
education in medicine. The fury, for such it really is, has been 
likened to the sexual orgasm, with which it is undoubtedly allied, as 
the two are not rarely coincident when there is severe anal or genital 
itchiug. The features of the patient are drawn ; he is but half 
conscious of his ejaculations and surroundings ; with his nails or 
other object which he employs he attacks the too vulnerable skin 
with an incalculable savagery. In these exaggerated paroxysms, 
nothing but blood will suffice for his relief. ]STot till the torn and 
wounded surface oozes with red drops at every point does he emit the 
sigh which indicates that his desire is satisfied. Men and women 
forcibly withheld from doing themselves this severe damage, will at 
times exhibit the muscular spasm, facial expression, and movements 
of body, scarcely distinguishable from the symptoms of an epileptic 
seizure. This brief outline of a picture familiar to those who have 
had experience in exaggerated cases, will serve to enforce the need of 
the utmost care in selecting a topical remedy in acute eczema, the 
greatest gentleness in its application, and the nicest provision for the 
special needs of each individual patient. 

In proportion as the disease progresses to a subacute or chronic 
stage, the various topical medicaments employed may be changed in 
character so as to produce an astringent or stimulating effect upon 
the part. The utmost skill and prudence, however, are needed at 
this juncture; and when uncertain as to the proper course, it is well 
to continue the dusting powder, alkalinized gruel, oleated lotion of 
lime-water, or whatever other article may be externally employed. 
For it is at this time that the disorder is readily awakened to renewed 
activity, a turn of affairs which is especially annoying to the patient, 
and particularly so to the practitioner if there be a suspicion (truth 
to say, often too well founded) that the aggravation has been due to 
the treatment. It goes without saying, that the routine practice in 
eczema has long been to order an application of the benzoated oxide 
of zinc ointment, irrespective of particular features of the malady in 
any individual case. Xow no greater error in this special direction 
could be committed. The acutely inflamed skin will rarely tolerate 
the most perfectly medicated ointment ; and as this acuteness sub- 



332 DISEASES OF THE SKIN. 

sides, such tolerance is first to be carefully tested, as, for example, 
by applying a weak ointment to a part only of the affected surface, 
The term, " rarely" is, however, here used advisedly. With that 
singular capriciousness which distinguishes the eczematous skin of 
different individuals, the zinc ointment occasionally affords very great 
relief in the severest forms of acute vesicular disease. 

In the application of such ointments it should be remembered 
first, that they must be sweet and freshly and carefully prepared ; 
second, that they can be advantageously applied by gently rubbing 
them into the part by the tip of the finger, after which soft lint in 
strips, spread with the same material, may be neatly superimposed ; 
third, that an ointment, if selected, need not necessarily be applied 
to every part of the inflamed skin, since a little pad or circlet of lint 
may be applied only to an oozing or pustular patch ; lastly, that the 
debris of one dressing should be carefully removed before another 
application is made. Strata of any ointment, the older next to the 
skin possibly rancid and having imprisoned beneath them pus or 
other products of the disease, are a positive source of harm. 

One of the most valuable of the preparations useful at this period 
of the disease is some modification of the Lassar paste, in which two 
parts each of finely powdered talc or rice flour and zinc oxide are 
well incorporated with four parts of vaseline ; and from one to three 
per cent, of salicylic acid added to the whole. 

The most soothing ointments for use at this stage are the benzoated 
oxide of zinc salve which may be reduced with cold cream one-half 
or more for extremely sensitive conditions of the skin ; Hebra's dia- 
chylon ointment, described later, of which one part may be combined 
with three or four parts of vaseline or cold cream and from five to 
ten grains (0.33-0.66) of salicylic acid added to each ounce (32.) of 
the whole ; or the oleate of bismuth, prepared according to the for- 
mula of McCall Anderson given below. 

Appended are a few formulae for ointments useful in this stage of 
the disease : 



R. Zinci oxid. 5 ss; 2 

Hydrarg. ammon. chlorid. gr. v.- 9 ss ; 

Camphor, pulv. 3 ss- % j ; 2-4 

Ungt. aq. ros. %] ; 32 



38-66 

M. 



For the oxide of zinc may be substituted the subnitrate or the 
subcarbonate of bismuth ; or from two to four grains (0.133-0.266) of 
the red oxide of mercury ; or from four to ten grains (0.266-0.666) 
of the mild chloride ; or from ten grains to half a drachm (0.66-2.) 
of the ammonium chloride. The cold cream makes an agreeable 
basis for these ointments, though lard, simple cerate, lanolin, vase- 
line, or equal parts of vaseline and the other preparations answer a 
good purpose. The cerates are made sufficiently soft for gentle 
manipulation by adding a drachm (4.) or two of glycerin to each 
ounce (32.) of ointment, and maybe flavored with lavender, rose- 
mary, or bergamot to suit the taste. 




ECZEMA. 333 

The oleate of bismuth or zinc is prepared by rubbing up one 
drachm (4.) of the oxide of either metal with eight (32.) drachms of 
oleic acid, which is then allowed to stand for two hours. It is after- 
ward heated in a water bath, when ten drachms (40.) of vaseliue and 
three (12.) of wax are dissolved in it, the whole to be stirred until 
cold. It is especially useful when employed in the papular forms of 
eczema. 

The well-known diachylon ointment of Hebra occupies a foremost 
place in all lists of articles useful at this period of the disease, and 
even later. It is prepared as follows : 

Fourteen ounces of the best olive oil are added to two pounds of 
water, and heated to boiling in the water bath. Three ounces aud 
six drachms of an equally good article of litharge are dusted over 
the fluid in ebullition, which is constantly stirred throughout, in 
order to prevent the formation of fatty acids. During the cookiug, 
water is occasionally added as required. The stirring is to be con- 
tinued till the ointment is quite cold. 

Duhring has modified this ointment as follows : 

One part of freshly precipitated (from acetate of lead) pure white 
hydro- oxide of lead is rubbed down with two parts of water, and 
well mixed with six parts of the best Lucca olive oil. Stir the mix- 
ture for about two hours over a hot- water bath near the boiling 
point, and then cool with constant stirring until the proper consistence 
is obtained, and while the mass is cooling add one drachm of the 
oil of lavender to each half-pound of ointment. The preparation, 
according to Eisner, a Philadelphia chemist, is said to contain the 
oleostearate of lead. 

When properly prepared this ointment is perfectly homogeneous, 
of a light yellowish color, and of the consistency of butter. It has 
been modified by Piffard, and after him by Kaposi, in combining 
equal parts of lead plaster and vaseline. It is commonly flavored 
with the oil of lavender. It is technically known as the unguentum 
diachyli albi, of Hebra. It may be imitated fairly well by melting 
together two or three parts of olive oil, and four of diachylon plas- 
ter, stirring till cool. 

This valuable ointment, though useful often in full strength and 
even to the exclusion of all others, is yet with such others often 
combined with manifest advantage. Thus a drachm or two (4.-8.) 
of it may be added to the ounce (32.) of lard, cold cream, or cerate, 
with or without the addition of another drachm or two (4.-8.) of the 
oxide of zinc ointment, or even one of the tarry preparations to be 
mentioned later. 

For the management of acute eczema many rely to-day upon the 
salve muslins, glycerolates, pastes, etc., which are fully described in 
the chapter on General Therapeutics. Unna's paste is prepared by 
mixing one ounce (32.) of zinc oxide with two ounces (64.) each of 
glycerin and mucilage. To it one per cent, of carbolic acid or sali- 
cylic acid may be added, and the mixture theu applied with a brush. 
Veiel recommends as a mull for the face and genitals : 



334 DISEASES OF THE SKIN. 

K -feZbl& Simp1 -} »*«•! 10 

Adip. benzoinat. 3 ss ; 2 

[To make ben zoated sebum : 



M. 



R . Seb. taurin. 3yss; 101 

Benzoes subtil, pulv. grs. xv; l| M. 

Digere in balneo vapor, per horas duas et cola. 

To make benzoinated lard : 

R. Adipis 3 ij ss ; 101 

Benzoes subtil, pulv. grs. xv; l| M. 

Digere in balneo vapor, et cola.] 

With, these may be named the glycerole of starch, cucumber oint- 
ment, the emulsion of sweet almonds, the decoction of Irish moss, 
and Hardy's formula, two parts of the oxide of zinc, eight of gly- 
cerin, thirty of cold cream salve, and fifteen drops of the tincture of 
benzoin. 

In chronic eczema it is necessary at first to remove from the sur- 
face all dried products of the inflammatory process which usually 
remain upon the surface, such as crusts, scales, and masses of effete 
epidermis. For this purpose oil is to be freely used, and care should 
be taken that it is rubbed gently into every part of the affected patch. 
A species of oil poultice may also be applied by saturating pieces of 
flannel or layers of antiseptic cotton with either cod- liver or olive 
oil, and covering these with protective silk gauze and a light bandage. 
As soon as the inflammatory products are softened they are removed 
by washing with soap and water, using for this purpose either the 
ordinary toilet soap, or, where the skin will permit, the spirit of 
green soap, described in the chapter on General Therapeutics. 

The Sarg glycerin soap is an admirable substitute for these arti- 
cles when the skin is tender, and where an elegant toilet preparation 
can be ordered. The crusts and scales once removed, subsequent 
topical applications may be made as required in each case. 

The acuteness of the disease having fairly subsided, not only as 
regards the question of time but more especially as concerns the 
question of what the skin will tolerate, the tarry and allied prepara- 
tions become for the first time worthy of consideration. Valuable 
indeed when such toleration has become experimentally established, 
they are sources of positive injury when the acuteness of the inflam- 
matory process has not completely subsided. 

The articles of this class most commonly employed are pix liquida 
(pine tar), oleum rusci (the oil of white birch), oleum cadinum, and 
terebinthina Canadensis (the balsam of fir). The oil of cade, as 
found in most of the shops, is inferior to the oleum rusci, which is 
certainly the better of the two articles. They are best applied in the 
form of ointments, but are occasionally painted over the surface with 
a camel's-hair brush in a liquid state. From one-half to two drachms 
(2.-8.) of the tar, in combination with a suitable quantity of the 



ECZEMA. 335 

subcarbonate of potash, are sufficient to add to a single ounce (32.) 
of ointment, the proportions suggested being varied to suit the re- 
quirements of each case. In attempting to meet such requirements, 
it may occasionally be found useful to combine with these ointments 
the oxide of zinc, the mercurial compounds, or the diachylon oint- 
ment of Hebra, already described. 

The following formulae are illustrations merely of the manner of 
compounding these articles : 



R . 01. rusci (vel cadini) 


3ss-3jss; 


1-6 


Potass, subcarbonat. 


9j-3 ss ; 


.66-2 


Unguent, aq. ros. 


ij; 


32 


i. ungt. 







M. 

For the potassic subcarbonate one-half to one drachm (2.-4.) of 
the zinc oxide may be substituted, or from two to four grains 
(0.133-0.266) of the red oxide of mercury, or yet half a scruple 
(0.666) of the mild chloride. The vehicle also of such ointments 
may be vaseline, lanolin, simple cerate, or half an ounce (16.) of 
either in combination with an equal quantity of diachylon ointment. 

Of the fluid preparations may be mentioned alcoholic solutions of 
tar, half an ounce (16.) of the latter to the pint (512.) of alcohol ; 
and in cases where the detersive action of soap is also needed, the 
sapo viridis may be added as follows : 

R. Picis liquids f ^j-ij ; 32-64 

Sapon. virid. f ^jss-iij ; 48-96 

Glycerin. f |j ; 32 

Spts. vin. rectif. f^viij; 256 

01. rosmarin. f£>ss; 2 M. 

Sig. To be rubbed gently into the skin with a flannel rag. 

Dr. Bulkley, of New York, has devised an alkaline solution of 
tar and caustic potassa, which is especially serviceable, as it is mis- 
cible with water in all proportions. It is constituted as follows : 

R . Picis liquidse f ^ ij ; 64 

Potassse causticse % i ; 32 

Aq. destillat, |v; 160 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar 

with friction. 
Sig. " Liquor picis alkalinus." To be used diluted as a lotion. 

A drachm (4.) or more of this solution may be added to a pint 
(512.) of water; and, as an ointment, the same quantity to the ounce 
(32.) of cold cream, lanolin, or vaseline. It should be remembered, 
however, that the caustic alkali renders it exceedingly irritating to a 
sensitive skin, and it should be employed with caution upon any un- 
tested surface. 

The formula recommended by Spender and described in the chapter 
on General Therapeutics, is a useful means of testing the efficacy of 
tar upon an eczematous surface. When fluid or semi-fluid com- 
pounds of tar are needed upon the scalp, a drachm (4.) of the article 
selected may be rubbed up with an equal quantity of glycerin, and 
added to six ounces of Cologne water (192.). 



336 DISEASES OF THE SKIN. 

Hebra disclaimed any special value for sulphur in eczemas uncom- 
plicated by the acarus scabiei, but in Wilkinson's and other oint- 
ments it has certainly served a good purpose. The following formula 
supplies an ointment rather less severe, which has practical efficacy 
in chronic eczema : 

128 
32 
16 



Sig. 



B • Picis liquid, (vel ol. rusci) 


3iv; 


Adipis 


Ij; 


01. olivee 


3 ss ; 


Misce et adde 




Terebinth. Canadens. \ 
Sulphur, flor. J 


aa gj ; 


To be applied three times daily 


with a soft brush 



32 



M. 



To this may be added the green soap, if a stronger effect is de- 
sired. 

Olive or cod-liver oil may be rubbed into the eczematous skin, 
after combination with equal parts of one of the tarry preparations ; 
and carbolic acid in lotion or ointment, with the balsam of Peru, 
though less effective, answers well in many cases. 

Ichthyol, in ointments of the strength of ten per cent, and less, is 
useful in localized patches of the disease, especially of the papular 
and scaling varieties. The ammonium sulpho-ichthyol is preferable 
to the natrium compound. Its influence upon the skin seems to 
resemble both that of the tars and of chrysarobin, and cannot be 
regarded as greatly, if at all, superior to these agents. 

Whichever article be selected, it should be thoroughly rubbed into 
the affected surface several times in the day, after a small portion of 
the skin has been attacked to test its susceptibility. Should the 
redness, itching, secretion, and infiltration be aggravated by such 
application, it will be needful, for a time at least, to exchange the 
local treatment for one less stimulating. Should, however, the tarry 
or other similar application be well borne, it should be reapplied till 
it is no longer washed away by the ooze from the skin. Sometimes 
it is well to permit the former to accumulate till it is naturally shed 
from the surface by exfoliation, a course which will be indicated by 
the absence of all local distress. The new epidermis which forms 
beneath such coating, should be for a time protected by a dusting 
powder. Occasioning no further subjective sensation, it speedily 
loses its redness and assumes a normal appearance. 

In other cases, indicated by local distress and exaggerated secretion, 
it will be found useful to completely remove the tarry application. 
After saturating it for a few hours with oil, the surface may be 
cleansed with a weak alkaline lotion, and the tar compound then 
reapplied to the oozing skin with flannel or a camel's-hair brush, 
according as recourse is had to an ointment or solution. 

Hebra used to employ in chronic eczema of obstinate kinds a 
remedy which he claimed to be his ultimum refugium, and which 
" cures every case without exception," the concentrated liquor potassse. 
The objections to its use are, however, grave. It produces severe 
pain, and in inexperienced hands it is dangerous. As a consequence, 



ECZEMA. 337 

this distinguished dermatologist adopted two methods which he re- 
garded as partial substitutes for it. The first was the inunction of 
the body thoroughly and firmly with green soap, which was not re- 
moved by washing, but left in contact with the skin for several days, 
while the patient was wrapped in blankets. The second was his 
well-known method of treating more circumscribed patches of chronic 
eczema with soap washing and ointment, the process being described 
below in nearly his own language : 

A piece of green soap, as big as a walnut, is spread upon a flannel 
rag, and rubbed into the eczematous part for several minutes, press- 
ing firmly the while, and from time to time dipping it into water in 
order to produce a better lather. The part is then washed free from 
suds with water, carefully dried, and the oil or ointment selected for 
topical use immediately applied on strips of muslin. These are neatly 
bandaged to the part. The soap must be rubbed in at least twice 
every day, so long as any excoriated points appear after its applica- 
tion. Soap rubbed into the healthy skin will not be followed by such 
effects, the part feeling clean, smooth, and comfortable after it has 
been washed off with water. The contrast this offers to the eczema- 
tous parts is very striking, the latter presenting numerous intensely 
red, raw, and moist spots. These are all caused by the action of the 
soap in softening and destroying the layer of cuticle which was before 
undermined by the eczematous fluid so as to form coverings for vesi- 
cles. Each, therefore, represents the floor of a vesicle, the roof being 
removed. The appearance of these red, shining, moist points after 
the first inunction suggests to the inexperienced eye that the malady 
has been aggravated ; but they become fewer in number after each 
application, and finally entirely disappear, the eczematous surface 
being then no more affected by the soft soap than is the surrounding 
healthy skin. 

For the production of marked effect upon different patches of the 
eczematous skin — those, for example, upon the palms and soles 
characterized by callosities, thickening, or even verrucous growths — 
a ten per cent, salicylic acid salve can be used after the shampooing, 
or Unna's salicylated gutta-percha plaster mull. 

Energetic effects are also obtained by the use of n&phthol, chrysa- 
robin, and pyrogallol, in the strength of from one part to ten, to 
one part to thirty of salve. It is well to begin with a strength not 
exceeding one to two per cent., and gradually increase. 

Frazer 1 speaks highly of the application of iodoform to eczematous 
patches. It is employed in the form of an ointment, containing 
from ten to thirty grains (0.66-2.) of powdered iodoform to the 
ounce (32.) of cerate. 

Other stimulating articles have been found useful in the treatment 
of eczema. Among these may be named cantharides, employed as a 
blister, the nitrate of silver in crayon or solution, three to ten grains 
to the ounce, and iodine in combination with carbolic acid. The 

1 British Medical Journal, July 16, 1881, p. 80. 
22 



338 DISEASES OF THE SKIN. 

following formula should furnish a clear vinous-red fluid, which may 
be applied pure or in dilution : 

R . Iodin. tinct. g ss ; 2 

Acid, carbolic, (ciyst.) £j ; 4 



Glycerin. \ . .. R 

Alcoholis / aa 5y, » 

Aq. destillat. ad f ^j ; 32 
Sig. Iodized solution of carbolic acid. 



M. 



In cases where there is considerable pruritus, especially in obstinate 
patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for this. The formula is : 

&. Iodinii ciyst. ") . J 

Acid, carbol. J cc oj > 

Combine with gentle heat and add an equal part of glycerin. 
Sig. Iodized phenol ; to be applied twice daily with a glass rod. 

Balmauno Squire, of London, has suggested a substitute for the 
diachylon ointment, in the glycerole of the subacetate of lead. It 
is certainly a valuable preparation in many cases, but not superior 
to the other ointment named. The " stock " is prepared as follows : 
Take five parts of the acetate of lead, three and one-half of litharge, 
and twenty of glycerin ; heat for half an hour in a boiling glycerin 
bath, constantly stirring, and filter in a gas-oven or other kind of 
heated apartment. From one-half a drachm to two drachms (2.-8.) 
of this stock, added to the ounce (32.) of pure glycerin, are suffi- 
ciently stroug for application to the oozing surfaces of eczema rubrum. 

Lassar 1 recommends that the part affected should be at first well 
soaked with antiseptic oil, of which a considerable quantity is 
absorbed by the skin. A muslin bandage, soaked in oil, is then ap- 
plied, and covered w T ith oil-silk. The oil may be rendered antiseptic 
by the addition of one to two per cent, of carbolic or salicylic acid, 
or one and one-half per cent, of thymol. Sometimes the carbolic 
acid can only be borne for a short time, as it will of itself produce 
eczema. Rape-seed oil may be used in place of the more expensive 
olive oil ; but drying oils, such as linseed oil, are to be avoided, as 
they may cause inflammation. In chronic eczema, especially in in- 
fants and in eczema of the face, he recommends an ointment. The 
formula for an ointment which cannot be rubbed off during sleep, in 
eczema of the face, is : 



R • Acid, salicylic. 


3 ss ; 


2 


Zinc. oxid. 


3 v J; 


24 


Aniyli 


3vj; 


24 


Vaselin. 


3ij; 


64 



M. 

Wyndham Cottle has employed chaulmoogra oil, or gynocardic 
acid, in a large number of cases of eczema occurring in persons with 
delicate skins, and over such exposed surfaces as the face, hands, and 
arms. In both acute and chronic forms he has employed these sub- 
stances in the form of ointment, in the strength of from fifteen to 

1 Annal. de Derm, et de Syph., Sept., 1881. 



ECZEMA. 339 

twenty-five grains (1.-1.5) to the ounce (32.) of vaseline. The oint- 
ment is applied several times in the day, and, if possible, kept in 
contact with the part on rags over which it has been spread. 

Other mercurial preparations than those named above have long 
been in favor for application to localized patches of the disease. 
Among these may be named corrosive sublimate, the ammonio- 
chloride, the iodide and biniodide, the two oxides, and the nitrate. 

Calomel, which is exceedingly useful in the strength of a scruple 
to a drachm (1.-4.) to the ounce (32.) of zinc, lead, or simple ointment, 
can be often advantageously employed also as a powder in full 
strength, or diluted with bismuth or starch. In localized patches of 
papular eczema, where such a dressing can be tolerated, marked re- 
sults follow this dry dusting of calomel over the part, followed 
by alternate superposition of neatly adjusted strips of surgeon's 
plaster — the whole kept in situ by means of a neat bandage. If the 
itching is alleviated by such a dressing it can be reapplied for a week 
as soon as it is loosened, when the redness and infiltration will be 
found greatly reduced. 

Other surgical appliances used in the local treatment of eczema 
are Martin's solid rubber bandage, Fox's tubular bandage of rubber, 
and other dressings composed of starch, gutta-percha, and plaster of 
Paris, intended to support the extremities when the integument is 
weakened. None of these are equal to rest in the recumbent posture. 
The most useful purpose subserved by rubber in the treatment of 
cutaneous affections is to provide an impermeable outer dressing for 
watery and oily applications. Here the mackintosh and silk pro- 
tective of the Lister dressing answer all the indications. 

In the management of seborrheic eczema, the remedies found of 
greatest service are sulphur, chrysarobin, pyrogallol, and resorcin. 
Unna applies one part each of finely powdered resorcin and glycerin 
with sixteen parts of spirits of wine diluted with four times the 
quantity of water or chamomile tea. This is applied on cotton wool 
and covered with impermeable tissue. 

The plaster mulls of the same author are useful in the manage- 
ment of this and other forms of the same disease ; the objection to 
their use in this country (not applying to Germany and England 
where they are most in favor) lying in the frequency with which the 
imported mulls undergo chemical changes rendering them wholly 
unfit for local use on the tender skin. The bassorin pastes lately 
suggested as vehicles for topical medicaments are of considerable 
value. All the many parasitic forms of eczema require treatment 
directed to the removal of the cause, and many of the methods of treat- 
ment hitherto employed with advantage doubtless owe their efficacy to 
their antiparasitic effect. Many of the post-eczematous boils, the 
mixed forms of eczema-impetiginodes and the like, 1 are the result 
solely of inoculation of the skin with pus-cocci ; and are to be pre- 

1 Cf. an admirable paper on " Kecent Advances in the Etiology of Diseases of the Skin," by- 
Walter G. Smith. Dublin Journ. of Med. Science, January, 1892. 



340 DISEASES OF THE SKIN. 

vented by complete antiseptic care of that organ daring an eczema- 
tous attack. 

Prognosis. — Eczema is an entirely curable disease, but uncertainty 
attends its prognosis as regards the duration of an attack and the 
probability of the recurrence of a relapse. With respect to the 
questions most frequently asked, those relating to contagion, heredity, 
aud persistent lesion-relics, naturally a favorable response can be 
made. But the tact remains that some forms of the disease are 
insignificant, some persistent, and some peculiarly liable to relapse 
from very slight provocation. Only after careful weighing of all the 
conditions exhibited by the skin and by the other organs of the patient 
can a reasonable probability as to the future be estimated. Eczema 
is a disease exceedingly common, and subject to aggravation by causes 
well nigh innumerable. Were the physician always in position abso- 
lutely to insure his patient the exclusion of all sources of irritation, 
the prognosis would be much more satisfactory. In hospital patients, 
where such control is more perfectly attained, the results of treatment 
may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily re- 
lieved by proper treatment than the chronic forms of the disease ; 
that eczema with a discoverable cause is more manageable than one 
whose etiology is obscure ; that eczema of the very young and of the 
very old is at times particularly rebellious ; that the non-discharging 
phases of the disease are rather more persistent than those accom- 
panied by secretion ; that eczema lingering at the mucous outlets of 
the body (auditory canal, nostrils, mouth, nipple, anus, vagina) is 
more obstinate than when it affects the skin of other parts (shoulder, 
neck, lumbar region) ; that eczema with constant aggravation or 
complications (fissure of the hands, varicose veins of the leg, appa- 
ratus for anchylosis of knee) is more stubborn in proportion as those 
complications or aggravations cannot, from the circumstances of each 
case, be set aside ; and, finally, that an eczema which has long existed, 
or repeatedly recurred, as, for example, with every season of extremely 
cold or hot weather, is after relief, extremely liable to return. Eczema 
seborrhoicum affords brilliant results in all well managed cases. The 
parasitic eczemas are also particularly amenable to treatment. 



The Local Varieties of Eczema. 

Eczema of the Scalp. [E. Capitis. E. Capillitii.] 

When the scalp is affected with eczema, the symptoms differ some- 
what, according to the age of the patient. In adults, the erythema- 
tous and squamous varieties of the disease are more common ; in 
infants and children, the pustular. In the former the eruption is 
usually circumscribed and in patches ; in the latter it is more diffused. 
In the same proportion also the former is generally asymmetrically 
and the latter symmetrically developed. 



LOCAL VARIETIES OF ECZEMA. 341 

In infants and children, the pustules rupture early; and their 
contents dry into dirty-whitish, yellowish, or greenish crusts, matting 
together the hairs, serving as foci for dust accumulation and nests for 
lice, superimposed upon a reddish, oozing, pus-covered, or occasionally 
indolent skin, often foul-smelling, and usually complicated by a 
seborrhcea. The so-called " milk-crust " is usually a compound of 
dried pus and altered sebum. The itching is not so intense as in 
some other forms of the disease. Post-cervical, pre-auricular, and 
occipital adenopathy are common, and in strumous children suppura- 
tion of the affected glands may occur, though this is rare. The 
causes of this form of the disease are evidently associated with local 
conditions. The rapidly growing hairs of the scalp are in intimate 
association with the numerous and large sebaceous glands of the same 
part, which unquestionably respond at times to the physiological 
stimulus they feel, by an exudative process. The acne of the young 
man whose beard is growing, illustrates the same fact. Local irri- 
tants are not often wanting to push the disturbed equilibrium into 
the scale of disease. Dr. White calls attention to the common neglect 
in removing the " pre-natal cap of cheesy material/' as well as to the 
rude and unskilful attempts to accomplish the same end. Extremes 
of temperature, friction, excess, neglect, and absence of endeavor to 
wash the scalp, all these contribute to originate or aggravate the 
disorder. 

The affection when complicated or induced by lice, is more common 
in children than in infants, doubtless in consequence of the greater 
independence of the former and their gregarious habits. In girls 
with relatively long hair, the ova, or nits, of the parasite are readily 
distinguished, adhering closely to the hairs and accumulated espe- 
cially about the occipital region. The itching is usually more annoy- 
ing than in pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhcea, when scratch- 
ing or irritant applications have been made. The eruption here 
usually occurs in asymmetrical patches, or may be limited to a single 
patch tolerably well-defined in outline, and this often upon one side 
of the scalp, not as in infancy, preferring the vertex. Reference is 
made in the chapter on Seborrhcea to a form of eczema of the scalp 
occurring in adults where finger-nail sized, circular, oozing or slightly 
crusted patches are generally disseminated over the surface. They 
result, as a rule, from the scratching of an obstinate seborrhcea in 
" nervous 77 women ; and suggest traumatism, in their reddish friable 
crusts, the color being due to exuded blood. 

The diagnosis of these forms of disease has been already con- 
sidered. 

In the treatment of the eczema of the scalp in infants and chil- 
dren, the first indication to be met is the removal of the accumulated 
crusts. When this is harshly accomplished, it becomes a fruitful 
source of further mischief; it is, therefore, necessary to proceed with 
great gentleness, and thus the thorough softening of the crusts is all- 



342 DISEASES OF THE SKIN. 

important. For this purpose it is necessary to soak thern in oil and 
to retain this substance in intimate contact with the scalp. Olive or 
cod-liver oil may be selected, and if needful to correct the odor or for 
other purpose, one drachm (4.) of carbolic acid may be added to each 
pint (512.) with two drachms (8.) of the balsam of Pern. A neatly 
fitting skullcap should be then smoothly applied, constructed of the 
Lister protective or flannel, and fastened in place by a light bandage, 
never by elastic rubber bands. After several hours of soaking, the 
crusts should be removed by warm water and spirit of soap washing, 
and the entire process be repeated till the crusts are completely 
detached. In selecting an article for subsequent medication of the 
scalp, it should always be remembered that even infantile eczema will 
proceed to a natural involution if unirritated. Hence the oleated 
lime-water, or oil of sweet almonds alone, will often answer better 
than an ointment, and, even where there is considerable acuity of the 
inflammatory process, lime-water alone, with possibly a small quantity 
of glycerin added. In other cases the lime-water can be better 
medicated with calomel or the oxide of zinc. At times, also, it is 
well, even when these applications are kept in constant contact with 
the scalp, to order that a small pea-sized mass of one of the ointments 
described above [such as the benzoated oxide of zinc ointment with 
cold cream, or one medicated with a mercurial compound, e. g., calo- 
mel, twenty grains (1.33) ; or white precipitate, ten to twenty 
grains (0.66-1.33) ; or the subnitrate of bismuth half a drachm (2.) 
to the ounce (32.)], be applied at the time of the dressing. This is 
to be gently rubbed in the surface with the tip of the finger, and the 
skin afterward protected as before. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it certainly is a more expeditious method of arriving 
at the end, when a nurse has to dress the heads of several children in 
a single ward. In adults, especially in women, the hair should be 
spared, while the patient is warned that the loss of the growth upon 
the scalp may be considerable. As a sequel of obstinate seborrhcea 
such an eczema may be succeeded by alopecia. ; in the absence of the 
former, the hairs are usually reproduced. It is rarely necessary to 
employ the skullcap in adults, since one can succeed in insuring the 
necessary applications by directing the attention of the patient to the 
necessity of care and thoroughness. 

Lice when present may be destroyed by the application of petro- 
leum. Nits are removed from hairs which it is not desirable to cut, 
after the petroleum dressing, with alcohol or cologne water. 

As the disease in both classes of patients advances to a subacute 
or chronic stage, the treatment may be changed so as to include the 
various stimulating applications already described, such as ointments 
and spirit lotions containing tar, oil of cade, balsam of fir, pyrogallol, 
alcohol, and sulphur. In the case of infants, however, such stimu- 
lating topical remedies are very rarely to be employed. An eczema 
of the scalp which has once entered upon resolution, in an infant or 
child, should be generally soothed and protected. 



LOCAL VARIETIES OF ECZEMA. 343 

Many little patients thus affected are in excellent general health, 
and require no internal medication. Others, however, demand the 
interposition of the wisdom of the physician to protect them from 
the ignorance or folly of those to whose charge they are intrusted. 
Here is not space for a discussion of the pressing questions relating 
to the nutrition of the infant deprived of the breast and starving on 
the " proprietary" diet purchased of a chemist, or an equally vicious 
aliment compounded by lime-water, and imbibed through a tube by 
which it is flavored with India-rubber and the chemically altered 
casein of milk several days old. Fresh and pure or sterilized milk, 
animal broths, cod-liver oil, must not be neglected. This concerns 
the health of the child, and has indirect connection with the eczema. 
Among one hundred infants dead of artificial foods and marasmus in 
public charities a case of eczema will scarcely be recorded. 

Lastly, patients of both classes are to be saved from mercury, 
arsenic, and the iodide of potassium. 

Eczema of the Face. [E. Faciei.] 

Erythematous eczema of the face in adults is projected prominently 
among the varieties of the disease by its uniformity of type. It 
occurs in early and middle life and advanced years ; and is a par- 
ticularly intractable ailment. In well-marked cases, the forehead, 
cheeks, eyelids, and nose of the patient are involved, exhibiting an 
infiltrated, usually dusky -red, often symmetrical patch of disease, the 
affected surface being slightly elevated above the level of the sound 
skin. This surface is uniformly smooth and reddened ; occasionally, 
near the root of the nose and about the lower line of the forehead, 
minute, closely set papules are visible. Very slight oozing, especially 
after irritation, may be noticed. At the height of the disease or in 
its involution, exceedingly fine scales form, which are scarcely per- 
ceptibly shed from the surface. The lids, especially the lower lids, 
in advanced years, become puffy. The line of demarcation is unusually 
distinct, and rarely invades the scalp-border or the region of the 
beard. Itching is at times intense, the patient complaining of this 
bitterly, and usually preferring to rub the face with the hands or 
pieces of cloth. Sometimes, however, the face is well scratched with 
the nails, and excoriations and blood-crusts disfigure the countenance. 
Patients of intelligence usually describe the itching as paroxysmal, 
and starting at the root of the nose, whence it travels upward over 
the forehead, and laterally to the brows, often in the line of the 
supra-orbital nerves. Certainly at the root of the nose, the exudative 
process is of the most marked character. The eruption also is seen 
in asymmetrically disposed patches of various sizes, with islets of 
sound skin between. In typical cases the hairs of the eyebrows are 
reduced to a stubble by constant rubbing. In resolution of the sym- 
metrical form, this is commonly observed. 

Patients thus affected are often those whose faces have been espe- 
cially exposed to irritation, such as locomotive engineers, wheelsmen 



344 DISEASES OF THE SKIN. 

of sea-vessels, mechanics in trades where the hands are soiled with 
irritants and afterward applied to the face, and women spending 
hours of each day over the laundry-tub or the kitchen-stove. In 
each class the operation of the cause is made manifest by the exacer- 
bation of the disease after exposure. 

The affection is most commonly mistaken for erysipelas, a disorder 
from which it is readily differentiated by the chronicity of its course. 
The latter feature is particularly characteristic of this form of eczema. 
It is rarely completely relieved after the age of sixty within a twelve- 
month ; and, when it has existed for a long period of time, is partic- 
ularly obstinate under the best treatment, recurring with exasperating 
frequency upon exposure of the face to atmospheric changes. The 
great vascularity, abundant supply of sensory nerves, and necessary 
exposure of the face, probably explain this peculiarity. In its treat- 
ment the dusting powders fulfil an important part. Soothing appli- 
cations should always be first employed. The more stimulating 
applications may be tried later. 

In patients of younger years the face is apt to display vesicular 
and pustular phases of the disease, forms more often of acute eczema, 
and correspondingly more manageable. The itching, and especially 
burning sensations, are apt to be severe ; crusts form rapidly ; and 
in infants the picture presented is often that seen in the scalp, except 
that the hairs are not matted into the crusts ; and there is often a 
reddish blush at the edge of the crust ; or, when the latter has been 
removed, a redness of the oozing surface somewhat more marked 
than the similar patches on the less vascular scalp. The scratching 
in these little patients is severe ; crusts are torn off in part or wholly ; 
blood- crusted excoriations are common. The area of surface involved 
is in this way clearly extended ; sleep is greatly disturbed ; and the 
irritability and fretfulness of the child, thus produced, bear heavily 
upon its general nutrition. In severe cases of long standing the 
mental tone of the little sufferers becomes singularly perverted, and 
the character unquestionably changed. The eczema of the cheeks and 
chin of infants is often due to the reflected irritation of the eruption 
of the teeth. 

This chain of formidable symptoms well linked together will often 
bid defiance to the most skilled efforts to impart ease to the tormented 
skin. In such cases the harness employed by Dr. White, of Boston, 
fills an important office. The skullcap, described above, and made 
of firm old cotton or linen cloth, is closely fitted to the calvarium, 
and a mask of the same material is shaped to the face with exactly 
placed apertures for the eyes, nose, mouth, and ears. It is gathered 
in beneath the chin, and laps over two inches at the back of the head. 
This may be used only during sleep, or, in aggravated cases, also during 
the hours of wakefulness. A species of strait-jacket is made by 
passing the head of the child through a hole in the closed end of a 
small pillow-case, which is then drawn down over the body and 
arms, and the latter confined at the sides by stitching the case together 
between the trunk and the upper extremities, or accomplishing the 



LOCAL VARIETIES OF ECZEMA. 345 

same end with safety-pins. The jacket is finally secured by similar 
means between the thighs. When it is necessary to imprison the 
lower extremities, these are similarly secured by pins within the case ; 
and the outer edge of such trousers can be fastened to the bed or 
cushion on which the child reclines. Of course this treatment does 
not preclude the employment of the washes, ointments, etc., which 
are to be neatly applied next to the skin beneath the " trousers " or 
"jacket." The result is that rest is given to the tormented skin, 
which is not suffered to be exposed to a single scratching even during 
the dressing of the parts ; and its natural tendency to repair soon 
brightens up the case. 

In the treatment of these cases the black wash and zinc salve 
treatment will be found valuable, as also the diachylon salve, Lassar 
paste, boric acid ointment, lead lotions, and the glycerole of starch. 
Van Harlingen gives the following : 



. Pulv. zinc oxid. 


3j; 


4 


Sevi purificat. 


3ij; 


8 


Adipis 


3iv; 


16 


Pulv. ulmi nav. 


q. s., 





M. 

To protect the face from cold air he also employs half an ounce 
(16.) each of glycerin and gum tragacanth, half a drachm (2.) of 
borax, and water sufficient to make a paste. 

In obstinate cases of adults, tar should be employed. It is well 
to remember in the management of any case, that while a tarry ap- 
plication may be well tolerated over one part, as, for example, on 
the cheeks and near the nose, in another, as, for example, over the 
lids, a zinc salve may be better employed in the same individual. 

Eczema of the Lips. [E. Labiornm.] 

Reference has been already made to the obstinacy of eczema occur- 
ring near the mucous outlets of the body, a result due, probably, to the 
secretion furnished by the adjacent mucous tracts. The lips furnish 
an illustration alike of this pertinacity and aggravation. Their 
frequent motions in mastication and articulation aggravate an eczema, 
which is, moreover, apt to be teased by a no less freouent thrusting 
of the tongue out of the mouth, where there is no beard, to wet the 
parts with mucus and saliva. One or both lips may be involved, 
vesicular, pustular, squamous, and erythematous lesions occuring at 
one point, or along the entire line of either, with frequently resulting 
crusts and fissures. The vermilion border of the lips commonly 
participates in the process. The lips become hot, and sometimes much 
thickened by the swelling and infiltration, their mucous faces being 
rarely implicated. Scarlet, dull red, and other peculiarly purplish 
hues of the vermilion border become visible. The parts are more 
picked than scratched, though the itching is at times severe. The 
pustular and vesicular forms are more common in children. The 
erythematous form, its reddened outline roughened by scales, evenly 
projected beyond the vermilion border, is rather an affection of 



346 DISEASES OF THE SKIN. 

maturer years. In many cases the disease is aggravated by nasal 
discharges which flow over the lip, giving the latter an elephantiasic 
aspect or even the appearance of an animal's snout, a condition noted 
also in later life. Occurring upon lips covered with the hairs of the 
moustache, the disease exhibits the usual symptoms of eczema barbae, 
in some cases the picture is that of a typical eczema seborrhoicum. 
In male patients, the pipe, the cigarette, the cigar, and the tobacco 
chewed and expectorated may aggravate the malady. In all cases it 
is obstinate, and calls for either emollient, stimulant, or protective 
applications. In cases displaying acute and painful symptoms, fre- 
quent fomentations of the part with soft rags dipped in hot mucila- 
ginous and alkaline waters, will aid in controlling the swelling and 
alleviating the pain. In chronic cases, where stimulation is de- 
manded, this can be effected at the time of dressing, the parts being 
subsequently protected by collodion or other material. Carbolic acid 
and the nitrate of silver are often needed for such dressing. In 
eczema of the hairy lip it is often of great service to remove the 
moustache by epilation or shaving. 

Fox suggests the use of thymol, five grains (0.33) to the ounce 
(32.) of cold cream. Van Harlingen applies equal parts of dilute 
phosphoric acid, glycerin, and syrup; and to the outer edge of the 
lip, two scruples each (2.66) of zinc oxide and honey, six drachms 
(24.) of the oil of sweet almonds, and two drachms (8.) of wax. 
Veiel paints the lips twice daily with soft soap. Taylor's application 
of the tincture of benzoin, each ounce (32.) containing one to two 
grains (0.06-0.13) of corrosive sublimate, is a valuable solution for 
painting over the cracks and fissures near the angles of the lips. 

The diagnosis is between hyphogenous sycosis, herpes labialis, aud 
epithelioma, the points of difference having been already suggested. 
The first is accompanied by loosening of the hairs, and caused by a 
vegetable parasite ; the second is vesicular in lesion, brief of duration, 
and trivial in severity ; the third is a disease of advanced years, 
rather than of early and middle life, and is never accompanied by 
itching, but usually by more or less ulceration. Syphilis is fond 
of the angles of the lips ; in most cases when thus limited, typical 
mucous patches of the mouth can be discovered. 

The lesions of syphilis at the angles of the mouth are seldom linear 
fissures, but more often irregularly outlined erosions, secreting a 
puriform mucus. Pustules and resulting crusts of the lips and nose 
in female children are often eczematoid features due to the picking 
and scratching solicited by lice upon the scalp. 

Eczema of the Nostrils [E. Narium] 

is naturally often associated with a chronic coryza. Iuasmuch as 
one of the common symptoms of hereditary syphilis is the "snuffles" 
of the child, the physician should carefully exclude the possibility of 
such disorder in every instance when an infant with coryza exhibits 
an " eczema" of the nares or lips. The age of the little patient; an 



LOCAL VARIETIES OF ECZEMA. 347 

inspection of its anal region (which should never be omitted in infan- 
tile eczema); and the history of the case will throw considerable light 
upon this important question. 

Whether occuring in the adolescent or child, the disease may 
linger only upon the alse in pustular or squamous forms, or block 
up the nares with crusts. In infants this enforces respiration with 
an open mouth, and the grasp of the nipple by the lips is thus inter- 
rupted either by respiratory acts or cries of agitation. The Schnei- 
derian membrane participates in the inflammatory process, and pours 
out its secretion upon the eczematous skin. The membrane when 
inspected is seen to be either raw and succulent, or in a condition 
analogous to that seen in the pharyngitis sicca of authors, dry, glazed, 
and free from discharge. The nostrils are often thickened in con- 
sequence of infiltration or fissured, especially at the lines of the nares 
laterally and inferiority. In severe cases, and when the lips partici- 
pate in this process, the pouting, swollen, and distorted organs suggest 
the snout of the lower animals. Adults as a result frequently suffer 
from coccogenous sycosis and furunculosis. 

Care should be taken to exclude syphilis in making a diagnosis, 
bearing in mind the fact that the pustular syphiloderm (which see) 
frequently selects the furrow on either side of the nares for its evo- 
lution. 

In treating these cases all crusts should be removed, and the parts 
carefully protected. Picking the nose in children should be pre- 
vented if needful, by the "strait-jacket." Pencillings with the com- 
pound tincture of benzoiu, iodized phenol, nitrate of silver, and 
collodion will often prove serviceable. In softening crusts, oil may 
be freely used. For this purpose the warm carbolized spray of the 
atomizer answers well, medicated with resorcin, which may also be 
efficiently employed for the relief of the nasal catarrh, often respon- 
ble for the disease in adult cases. Unna recommends drainage tubes 
in such patients, wrapped with lead ointment mull, and, after the 
softening of the crusts, painting every second day with yellow pre- 
cipitate ointment. In the same way a weak citrine ointment or white 
precipitate salve may be used. When the disease extends well up 
the nares, Neumann employs bougies made by combining two grains 
(0.138) of zinc oxide with sixteen (1.06) of cocoa butter. Hardaway 
recommends equal parts of cold cream salve and the glycerole of the 
subacetate of lead. 

Eczema of the Ears. [E. Aurium.] 

The ears are affected with eczema both in infancy and maturer 
years, rather more often in women and children, the disease being 
limited to the whole or part of the organ, or extending backward 
over the post-auricular region, or downward over the ramus of the 
superior maxilla. It may be acute or chronic, and originate in sebor- 
rheic eczema of the scalp or face; in chronic or catarrhal discharges 
from the external auditory meatus ; in the growth of the aspergillus in 



348 DISEASES OF THE SKIN. 

the same canal ; in exposure to temperature changes, especially when 
aided by high winds ; in frost-bite ; in the irritation set up by pedi- 
culi and by the auricular limb of the frame of spectacles ; in the 
toxic effect induced by the hook of cheap ear-rings and dyed bonnet 
ribbons ; in the traumatism of ear-piercing ; and in the habit of un- 
necessarily picking the ear to relieve it of wax or trifling sensations 
of irritation. 

The pustular and moist forms are common at the superior, inferior, 
and posterior boundaries of the pinna, where a linear fissure is apt to 
form in the line of the angle made by the auricle with the plane of 
the adjacent integument. The motions impressed upon the ear by 
handling it, placing the hat on the head and tying hat strings over 
it, always tend to aggravate the disorder. Long hairs worn over the 
ears may have a similar effect by the production of friction and the 
retention of heat. The lobules are apt to display the erythematous 
and scaly phases of eczema, becoming infiltrated, having a deformed 
appearance, lurid red color, and indolent course. The lobules alone 
of both ears in young women may be similarly affected, and exhibit 
these phenomena for consecutive years. Often the chronic inflam- 
mation may lay the foundation for a keloidal growth, an accident 
of several inflammatory processes in other parts. At other times 
the entire auricles present a similar appearance, uniformly dark red, 
infiltrated, alternately weeping and scaling, and projecting to a 
noticeable extent from the side of the head in consequence of their 
increase in bulk. The itching is usually more annoying than severe, 
being accompanied by a characteristic sensation of tenseness and ful- 
ness of the part. Like the eczema which occurs at the other mucous 
outlets of the body, the affection in these parts is particularly obstinate 
when it assumes a chronic form. Symmetry to the extent of involv- 
ing both ears, though commonly to a different degree in each, is 
rather the rule than the exception ; and is doubtless due to the simul- 
taneous operation of effective causes. 

The diagnosis is between erysipelas, seborrhcea (which occasion- 
ally occurs in the concha of the auricle), erythema simplex and 
multiforme, and dermatitis calorica. The mouth should always be 
carefully examined in these cases for sources of trouble. 

The treatment should be at first soothing and protective by the 
zinc salve or diachylon ointment ; afterward stimulating. A firm 
bandaging of the ears to the head may be required to support the 
parts, to prevent irregular pressure (head upon the pillow), and to 
secure contact with external medicaments. In chronic cases, stimu- 
lant applications are often well tolerated, and the tarry ointments 
here play an important part. Treatment appropriate to the otitis 
externa or aspergillus may be required. Bulkley recommends a 
tannin ointment, one drachm (4.) to the ounce (32.), deeply and 
thoroughly passed into the meatus on a camel's-hair brush. French 
authors generally recommend small tampons smeared with an oint- 
ment and left in the canal. Burnett employs two drachms (8.) of 
the oil of tar to one ounce (32.) of alcohol. Great benefit is derived 



LOCAL VARIETIES OF ECZEMA. 349 

from pencilling the indolent surfaces with solutions of the silver 
nitrate. The intractable forms almost invariably affect adults, and 
in them there is usually a history of improvement under treatment, 
then, in men, exposure, as, for example, to the wind, or, in women, 
excessive dancing, etc., and subsequent aggravation. 

Eczema of the Lids. [E. Palpebrarum.] 

Here the free edge of the lid, or the skin over the orbital margin 
of the tarsal cartilage, may be chiefly affected ; and these, both in 
children and adults. When the free edge of the lid is involved, 
there is present a species of coccogenous sycosis, the hair-follicles 
becoming inflamed and furnishing a purulent discharge which may 
agglutinate the lids. The latter are thickened and swollen, become 
the seat of a moderate itching, are picked rather than scratched, and 
exhibit minute crusts between, or glued to, the hairs. The disorder 
is often accompanied by a seborrhoea of the Meibomian follicles, and 
is described by oculists under the designation of " blepharitis " and 
" tinea tarsi." Inasmuch as the facial expression is quite character- 
istic when the lids are thus involved, patients exhibiting this form 
of eczema are usually set down as "scrofulous," though it occurs in 
many individuals with no other sign of struma, and eczema surely 
is not such a sign. 

Fissures occasionally form at the commissure of the lids. The 
disorder may complicate eczema of the other parts of the face. In 
the erythematous eczema faciei of adults there is usually swelling 
with puffiness, especially of the lower lid. The conjunctiva may, 
or may not, be implicated. A chronic granular condition of the 
lids is not noted as frequently as might be suggested by a priori 
reasoning. 

The edges of the lid should be carefully cleansed with a weak 
alkaline solution and soft camel's-hair brush whenever the lid itself 
is involved, then as carefully dried and anointed with cold cream. 
In acute cases the closed lids may be frequently bathed with warm 
alkaline solutions ; and strips of soft lint, soaked in the same mate- 
rial, or a very dilute glycerin or carbolic acid solution, may be laid 
over the closed lids for as long periods during the day as they are 
comfortably tolerated. In chronic cases the red oxide of mercury 
ointment, one grain to ten (0.066-0.66) to the ounce (32.), with or 
without an equal quantity of salicylic acid, has always been held in 
high esteem. Oculists, in the treatment of this affection, are fond 
of using an ointment of the yellow sulphuret of mercury. In place 
of these, the unguentum hydrargyri nitratis, one part to six of cold 
cream, may be applied, or resorcin one part to fifty of cold cream 
salve. Epilation of the eyelashes may rarely be necessary. Pen- 
cillings with solutions of the nitrate of silver in various strengths are 
also useful in chronic cases, but these must be carefully confined to 
the lids, and not suffered to come into contact with the conjunctiva. 
Excessive use of the eyes must be prohibited. 



350 DISEASES OF THE SKIN. 

In the diagnosis, care must be taken to exclude syphilis, lupus, 
and pediculi. The author has seen but one instance of piedra of the 
eye-lashes. Instead of the ordinary nits of the lash, there were in 
this case jet-black, small pin-head sized masses of ivory-like hard- 
ness attached to the hairs. 

Eczema of the Beard. [E. Barbae.] 

Eczema may involve the region of the beard only, or may spread 
to such parts from those in the vicinage, or may, finally, extend 
from the beard to other parts of the face. The first is common, and 
furnishes, perhaps, the best type of the disease ; the second is also 
common, but usually subordinate in importance to other trouble of 
the facial region. The last is decidedly the rarest. It is indeed a 
matter of surprise that an eczema should, as it often does, endure for 
years, limited exclusively to the region of the beard and never trans- 
gress these limits. 

This fact furnishes a convincing argument in favor of the local 
origin and of the frequency of local sources of aggravation of 
eczema. Rarely will one see a picture more suggestive to the unedu- 
cated eye of " scrofula" or Cl humors of the blood" than the face of 
a middle-aged man, with long-standing eczema of the entire region 
covered by the beard. The hairs are thinned, and fail to hide com- 
pletely the reddened surface beneath, covered here and there with 
pustules or floors of broken pustules, dried inflammatory products, 
yellowish and greenish scales and crusts. Beneath the crust the sur- 
face is smooth, not lumpy, as in hyphogenous sycosis. The hair- 
follicles are not solely involved, as in the coccogenous form of that 
disease, but evidently they and also the integument between them. 
In recent eczema the hairs are not loosened in their follicles, but in 
chronic cases such loosening does unquestionably occur, and there is 
a true defluvium capillitii. The disorder is evidently one primarily 
involving the skin of the region of the beard, and secondarily the 
hairs, extending smoothly over that surface, as smoothly as an 
eczema on the cheek of a woman. There is commonly a certain 
degree of symmetry, to the extent at least of involving the beard in 
different degrees on both cheeks at once, or the chin on both sides ; 
often the symmetry is perfect. This is rare in the several sycoses of 
the same part. 

The disease is accompanied by itching, rarely as severe as upon 
the smooth parts of the lace, is particularly obstinate, and extremely 
disfiguring. When extending into the region of the beard from 
other parts, it is usually associated with eczema of the ears. When 
limited to the region of the moustache, it may be connected with an 
eczema of the nares and a chronic nasal catarrh, or be a symptom of 
seborrhoic eczema. 

The explanation of the obstinacy of eczema of the region of the 
beard is to be found in the hairs which cover it. Whether the latter 
be long or short, feeble or strong, each during the twenty-four hours 



LOCAL VARIETIES OF ECZEMA. 351 

acts to a certain extent as a lever in motion upon the portion of the 
integument in which it is implanted. In conditions of health, the 
skin tolerates well this motion ; in disease it becomes a positive 
source of trouble. Multiply by thousands the impression produced 
upon the healthy skin when a single hair or group of hairs is moved 
by a strong current of air, by the fingers, by a brush, or by any 
other externally operating cause, and some idea may be had of the 
extent to which this force may become effective. But the best evi- 
dence of the fact is to be found in the results which follow the 
removal of the beard. Clipping short the hairs of the face w T ill not 
answer, though generally preferred by the patient as exposing to a 
less degree the unsightly surface beneath. Nothing short of epila- 
tion or shaving, and continual shaving every second day, will effect 
the desired result in chronic cases. As soon as the disease is reduced 
practically to an eczema of the non-hairy parts, it improves, in pro- 
portion to its distance from the mucous outlets of the body. When 
limited to the bearded cheeks, the most obstinate cases may be in 
the course of a single month robbed of one-half of their un sightli- 
ness. It may be needful to employ the usual methods — oil, hot 
water, and soap — to remove the crusts before the first shaving, and 
any imprisoned pus should be evacuated. The patient should be 
encouraged by reminding him that usually it is but the first step 
which costs ; each succeeding removal of the beard is accomplished 
with greater comfort to himself physically and mentally. After 
each epilation or shaving, the skin should be bathed in water as hot as 
tolerable, and, if at night, a lotion may be used, or an ointment, or 
the latter after the former. The salves most useful for this purpose 
are sulphur, one drachm to the ounce (4. to 32.) ; the diachylon oint- 
ment with salicylic acid, five to ten grains to the ounce (0.33-0.66 
to 32.), and the zinc or tar ointment. Earely the surface requires 
painting with weak solutions of the nitrate of silver. Best of all, 
however, is the dusting powder ; and, as soon as practicable, the 
patient should limit himself to this application. The shaving should 
be continued for months after the disease is at an end. It is, indeed, 
surprising to note in such cases how quickly the " scrofulous" look 
disappears, and the evidences of a " humor of the blood " are no 
longer evident in the face. The longer the limitation of the disease 
to the region of the beard, the more brilliant, as a rule is the result. 
It is not often necessary to resort to the tarry applications in this 
form of the affection. When complicated by eczema of the post- or 
infra- auricular region, stalactite-shaped crusts depending from the 
infiltrated lobule in consequence of the continuous drip of serum 
from above, eczema of the region of the adjacent whisker is less 
readily managed. 

Flat epitheliomata of the bearded cheek are not to be confounded 
with eczema barbse. The points of difference have been previously 
noted. It should be remembered also that the age of the patient, the 
career of the disease, the possible eversion of the neighboring lid, or 
agglutination of the adjacent lobe of the ear, distinctly high eleva- 



352 DISEASES OF THE SKIN. 

tion, or ulceration of tissue, absence of itching, and distinct localiza- 
tion of the disease, are all characteristic of this form of carcinoma. 

Eczema of the Genital Organs. [E. Genitalium.] 

Here the disease is remarkable for the severity of the subjective 
sensations it occasions ; for its tendency to persistence, recrudescence, 
and nocturnal exacerbation, and for the liability to the production of 
the sexual orgasm by the act of scratching. Iu men the surfaces 
most often involved are the anterior, posterior, or lateral faces of the 
scrotum where they meet the thigh, though the surface of the penis, 
as also that of the pubes and perineum, may be involved. In 
women, the labia majora, more rarely the labia minora and vestibule 
of the vagina are affected, with occasional extension of the disease to 
the same contiguous parts as in men. 

Eczema thus located is, as a French writer has well said, " a dry 
disease in a moist locality. " Vesicular and pustular forms are much 
rarer than the erythematous, the papular, the papulosquamous, aud 
the erythemato-squamous. In women, the moister forms are more 
frequent, doubtless because of the wider mucous outlet, and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, cedematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most 
severe cases. An eczema intertrigo at the labio-femoral angle is 
common. Over the whole may be poured the secretions from uterus 
or vagina, normal or pathologically altered. The disease is, however, 
sufficiently common after the menopause, when there is physiological 
atrophy of the uterus. 

The typical disease in men is recognized in the thickened, reddened, 
perhaps slightly scaling integument of the scrotum, which may also 
be fissured, excoriated by the nails, or covered by blood-crusts. 
Torn papules, even tubercles and nodose swellings often closely 
packed together, may be seen with a peculiarly lurid, even purplish 
hue. In exaggerated cases the infiltration is so great as to deform 
the parts, increasing the thickness and deepening the normal furrows 
of the scrotal integument to many times its normal dimensions, pro- 
ducing thus an elephantiasic appearance. In eczema of the penis the 
prominent symptoms are also oedema, itching, and redness with slight 
scaliness. 

In both sexes, as before stated, the attempts to relieve the itching 
are often as severe and prolonged as they are ingenious. Commonly 
no relief is obtained till a serous sweating or weeping of the thickened 
tissues is induced by the friction. Inasmuch as the latter is in severe 
cases frequently repeated, the physical dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are those 
more commonly registered by the physician. Though entirely 
unconnected with venereal disease of any kind, there is, for the 



LOCAL VARIETIES OF ECZEMA. 353 

many, a special dread of ao eczema of these parts, precisely because 
of its location. With sleep disturbed, the mind agitated, and the 
nervous system teased by an intolerable pruritus, one can scarcely 
wonder at the eloquence with which many patients describe their 
sufferings. It is a disease of middle life and advanced years. It is 
rare to see a well-marked, obstinate case in a child. 

The causes, exciting and aggravating, of eczema of the genital 
region are to be sought in heat, moisture, and friction. These 
primary factors are favored — first, by the effect of gravity, the organs 
in question being situated, when the body is in the erect positon, at 
the inferior apex of the double cone forming the trunk, and being 
thus subject to the force of gravity ; second, by the arrangement of 
the clothing in both sexes, by which heat and friction effects are 
heightened ; third, by uncleanliness, the secretions and discharges 
from the adjacent mucous tracts being suffered to accumulate upon 
the person ; fourth, by a long list of sexual errors which operate by 
obstructing what may well be termed the sexual ebb — that is, the 
natural reflux by which each periodical physiological congestion of 
these organs is by a natural process relieved. That the skin of these 
organs participates in such periodical congestion is a fact demon- 
strable to the eye. The abundant supply of bloodvessels, lymph- 
atics, and nerves to the parts, furnishes all necessary elements for the 
explanation of the formidable series of symptoms often displayed in 
eczema genitalium. 

In many eczemas of the surface, especially of the genital organs, the 
urine will be found to contain albumin or sugar, and these conditions 
have been supposed to lie at the root of the eczema. The diet for the 
eczematous patient with saccharine urine is of prime importance. In 
some cases, however, the eczema causes the elimination of the sugar 
or albumin, and not the reverse. Sugar and albumin are known to 
be producible in urine by external irritants, and, among the latter, 
by cutaneous diseases. Merely varnishing a portion of the skin has 
been followed by these effects. If patients with saccharine urine and 
severe genital eczema can be kept in bed, in the recumbent position, 
for a few days, while any soothing application productive of comfort 
is continuously applied to the tender and excoriated surface, the 
sugar will often rapidly disappear from the fluid excreted from the 
kidneys. These renal symptoms are in part reflex, resulting from 
the extraordinary irritation of the nerves distributed to the involved 
surfaces. 

The so-called diabetides genitales of French authors include some 
genital eczemas occurring in diabetic patients. But it is certain that 
many cases of very extensive and severe eczemas of the genital 
region in both sexes occur in patients in whom the most careful and 
repeated examination of the urine fails to reveal traces of sugar. 
The practitioner is urged never to omit such examination in his 
treatment of a typical case. 

In my personal experience patients exhibiting genital eczema with 
glycosuria may be distinctly separable in two classes. The first, and 

23 



354 DISEASES OF THE SKIN. 

most common, includes those presenting such marked physical symp- 
toms that the urine may be suspected before chemical examination. 
The patients are all extremely fleshy women given to an excessive 
consumption of beer. In these cases the sugar decreases pari passu 
with the eczema, if the beer be withdrawn and the local affection 
judiciously treated. In a second and much graver class of patients, 
also chiefly women, there is a diabetic history (often also of pul- 
monary tuberculosis), and the genital eczema is manifestly an epi- 
phenomenon. These patients are rarely obese ; usually the figure is 
that of a slender and delicate woman ; there is little, if any, use of 
alcoholic beverages of any kind ; and the local eczema is trifling in 
features as compared with that last described. In these cases, too, 
under the influence of an appropriate dietary and local management 
the genital eczema subsides, but the glycosuria persists to often grave 
issues. 

The treatment is to be conducted on the general principles hereto- 
fore enunciated. Sponging of the genital region with alkaline water 
as hot as can be well tolerated, followed by the blander oils and 
ointments at night, and the use of anti-pruritic dusting powders in 
the daytime, must not be omitted. In eczema of the scrotum, the 
suspender lined with lint which is wet with a lotion, smeared with 
an ointment, or thoroughly covered with a powder, can be usually 
employed to good advantage. The habit of scratching must be 
broken up at all hazards. In chronic cases, the treatment by soft 
soap and diachylon ointment will be found useful. Caustics, solu- 
tions of the mercuric bichloride and other mercurials, carbolic acid, 
and especially the tarry compounds, are often necessary. 

Finny, of Dublin, uses the following formulae, which are useful 
in allaying the irritation : 

R. Liniment, calcis f^iv; 128| 

Belladonn. extr. gr. xij ; 80 

Zinci oxid. 3 ij ; 8 

Glycerini ^3^'* ^ 

Aq. calcis f|;iv; 128 M. 

Sig. Lotion to be applied at night after bathing the parts in hot water. 

Be. Lin. calcis f^iv; 128 

Acid, hydrocyanic, (dil.) f £j ; 4 

Liq. plumbi subacetat. ^3^5 ^ 

Glycerini f 3 ij ; 8 

Aq. ros. adfgviij; 256 M. 

Sig. Cream, for application on strips of old linen. 

Or the Lassar paste may be used with advantage. 

Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated 
by intertrigo, the latter condition requires special relief by the inter- 
position of soft lint spread with an ointment. 

The diagnosis is between ringworm of the genitals, acne, pruritus, 
pediculosis, the venereal disorders, and herpes progenitalis. The 
first named may occur alone, or induce, or be grafted upon the 



LOCAL VARIETIES OF ECZEMA. 355 

eczema. It will be recognized by the discovery of the trichophyton, 
and is clinically distinguished by the crescentic edge of the spreading 
patch, with its convex border looking away from the genital centre. 
The " follicular vulvitis " of gynecological authors is a genital acne, 
and manifestly limited to the glands and peri-glandular tissues. The 
same is true of bromine and iodine acne, which may be developed in 
the same situation in both sexes. Genital pruritus may beget an 
eczema by scratching, but is accompanied by no proper skin lesion. 
The pubic louse is visible to the eye, as are also its reddish excreta 
and nits. The ulcers and sclerosis of the chancroid and primary 
syphilis are not accompanied by pruritus, and though occasionally 
multiple, never exhibit diffuse patches of disease. The syphilo- 
dermata are recognizable by their characteristic features and by the 
history of an infectious disease. In herpes progenitalis there are 
precedent burning, smarting, or neuralgic sensations, the occurrence 
of vesicles or groups of vesicles (lesions rare in eczema of the geni- 
tals), and frequent limitation of the disorder to the mucous surfaces 
or the muco-cutaneous lip by which such surfaces are bounded. In 
eczema such boundaries are usually respected, and the disease is much 
more strictly cutaneous. 

Eczema of the Anus and Anal Region [E. Ani] 

iu its etiology aud characteristics is closely allied to the same disease 
in the genital region. The presence of ascarides and haemorrhoids 
occasionally induces or aggravates the disorder ; though this is rarer 
than is commonly supposed, since multitudes of men and women who 
suffer from piles never complain of eczema. The eczema may occur 
in erythematous, squamous, or papular form, in the order named ; 
thus exhibiting here, as in the genitals, " a dry disease in a moist 
locality." 

The redness, infiltration, and itching may be limited to the verge 
of the anus, radiate from the latter in stellate lines, creep upward 
between the nates in the cleft, sweep forward over the perineum to 
the genital region, or extend laterally with intermediate intertrigo 
over the inner face of each thigh. Rarely the buttocks are covered 
with the same lesions. Fissures are apt to form about the anal 
orifice. 

The disease is common in infancy, where want of care in the 
removal of the napkin is a fertile source of mischief; and also in 
middle life and advanced years, when it becomes particularly intract- 
able. The itching is intense in the latter class, with frequent noc- 
turnal exacerbation. Unfortunately the scratching is often reflex, 
and practised during the unconsciousness of sleep, from which the 
patient is often roused by his or her manipulations. Pollutions fully 
recognized, or occurring during profound sleep, or, more usually, in 
states of semi-consciousness, complicate certain cases ; defecation be- 
comes painful. The harassed nervous system of the sufferer is often 
in a deplorably wretched condition. In cases of long standing the 



356 DISEASES OF THE SKIN. 

usual congested, thickened, infiltrated, and almost elephantiasic ap- 
pearance is presented, with exaggerations of the natural furrows and 
occasional fissures. The part may simulate in aspect the formidable 
conditions discovered in passive paederasty. Excoriations are common 
around the anal verge. 

The diagnosis is that of eczema of the genital region. 

In the treatment of these cases the use of very hot water by 
sponging, and the subsequent application of ointments, has yielded 
the best results. In the case of infants the dusting powders and 
blander ointments are alone to be employed ; in adults, especially in 
chronic cases, the tarry applications are especially valuable. Here 
the Lassar paste may be applied or the tincture of tar be freely 
painted over the surface, or one of the tarry ointments, such as 
the Wilkinson salve, of sufficient firmness to retain its form as an 
unguent when subjected to the heat of the part. Caustics are useful 
when there are fissures. Corrosive sublimate, one-half to one-quarter 
of a grain (0.033-0.016) to four ounces (128.) of the milk of 
almonds ; Squire's glycerole of the plumbic subacetate, half a drachm 
(2.) in two ounces (64.) of glycerin and water, or, as a substitute for 
the latter, the soft soap and diachylon plaster, are here of special 
service. Van Harlingen recommends almond oil containing twenty 
per cent, of carbolic acid. When defecation is painful the stools 
should be semi-liquid in order to insure non-aggravation of the local 
disorder ; not, it need scarcely be remarked, with a view to elimi- 
nating any materies morbi by purgation. Small tampons of cotton 
may be smeared with an emollient ointment, and gently inserted for 
a short distance within the anus. The tincture of benzoin, one part 
to ten of vaseline, may be used for this purpose. Kaposi recom- 
mends butter of cocoa suppositories, containing zinc oxide with 
belladonna or opium t When complicated by true fissure of the anus 
the sphincter ani must be stretched, divided, or dilated with medi- 
cated bougies. 

Besnier recommends the use of a clyster after each bowel move- 
ment, the fluid being retained for but a short time. At night, a 
cataplasm is applied. The parts are frequently washed with tepid 
water, and the anal tampons are smeared with cocaine. During the 
day, the oxide of zinc salve, thirty grains (2.) to the ounce (32.) of 
vaseline, is applied, and the parts are also thoroughly sprinkled with 
equal parts of the zinc oxide and subnitrate of bismuth in fine 
powder. Collodion medicated with one to three per cent, of salicylic 
acid, and lotions containing half a scruple (0.666) of the nitrate of 
silver to the ounce, are of great value in many cases. 

Van Harlingen suggests after the use of the hot bath, with the 
addition of starch and glycerin, an ointment composed of one part 
of cod- liver oil to two parts of suet. Veiel prefers the cautious use 
of chrysarobin to tar, employing the latter either in the form of 
spirits or as a tar diachylon, one part to twenty, gradually increased 
in strength. Carbolic acid and glycerin, a few drachms of each to 
to the pint of elder-flower water or almond emulsion, are specially 



LOCAL VARIETIES OF ECZEMA. 357 

indicated iu fleshy women when the disorder, as is often the case, is 
complicated with intertrigo. 

The key to most cases of anal eczema is to be sought in the dietary. 
The disorder, in adults particularly, is apt to be a significant symp- 
tom of gout, and without the dietetic and medicinal treatment of 
that condition, no local applications avail. Tobacco and alcohol are 
invariably to be excluded in the case of patients of this class ; and 
the alkalies, colchicum, and the salicylates are often needed. It is in 
these manifestations of eczema that the health resorts furnish their 
best results, necessitating and inviting, as they often do, an out-door 
life, an appropriate regimen, and an avoidance of stimulants. Even 
iu children and infants, when there are no ascarides in the rectum or 
vulva, the dietetic management of the patient should never be neglected. 

Eczema of the Nipple and Breast of Women [E. Mammae] 

is common in nursing women from either the irritation produced by 
the mouth of the infant, or, more commonly, in consequence of a 
galactorrhea. Eczema intertrigo is common below and between the 
breasts. The eczema here is vesicular, erythematous, or squamous 
in form, with fissures of the apex, side, or base of the nipple. The 
serous ooze from the infiltrated areas dries as usual into light-colored 
crusts. There are the characteristic buruing and itching. The dis- 
ease may occur on one or both breasts, and, especially with a galac- 
torrhea in summer, may spread extensively, covering both breasts, 
the surface of the belly, and the intermammary region. The circum- 
scribed forms occur also in pregnant or unmarried women, and are 
to be distinguished from scabies, which in women is apt to occur 
upon the breast. 

" Paget's Disease of the Nipple," or " malignant papillary derma- 
titis," the so-called eczema of the nipple and cancer of the breast, is 
designated by Thin 1 as a destructive or malignant papillary derma- 
titis. The mammary tumors here formed are found to originate in 
the epithelial lining of the lactiferous ducts, the elements of which 
undergo, at an early period of the disease, a cancerous transforma- 
tion. Clinically, there is usually observed in such cases a sunken 
nipple, its site occupied by a bright red or livid infiltrated patch of 
distinct outline, differing thus from the irregular definition of the 
contour of the eczematous area. In all cases of subcutaneous tumor 
or coincident axillary adenopathy, the physician should be especially 
careful in the matter of prognosis. 

Attention has been specially attracted to this form of epithelioma 
of the nipple and its areola, eczematous in appearance for only a 
brief period of its career, by contributions to the subject made by 
Darier and Wickham. These gentlemen would range Paget' s dis- 
ease with molluscum epitheliale and other disorders, as a group to be 
classed under the title of the psorospermoses. The parasite to which 
this name refers is of the order of the coccidise, or psorosperrnise, 

1 London Lancet, Amer. ed., June, 1881, p. 533. 



358 DISEASES OF THE SKIN. 

which they have recognized in microscopic examination of scales 
removed from affected areas of the skin. The parasites strongly 
resemble epithelium and are claimed to reproduce themselves by 
dehiscence and subsequent dissemination through the surrounding 
tissue. Other observers, however, have failed to differentiate the 
germs described, from epithelium undergoing metamorphosis in in- 
flammatory and other changes, and the conclusions on which it has 
been sought to establish a class of psorospermoses are as yet far from 
general acceptation. Paget's disease is more fully described in this 
treatise among the epitheliomata ; it is sufficient here to call attentiou 
to the important fact that an eczematoid patch, fairly well defined, 
surrounding the areola of the nipple or that organ only, with infil- 
tration, itching, and possibly a fissure of the nipple, or a crust cover- 
ing a superficial erosion, may be the sign of an epitheliomatous 
change already advanced either in the affected part only, or deeper 
in the galactiferous ducts of the breast itself 

The treatment of mammary eczema is in general that described 
above. In severe cases with galactorrhea, nothing short of weaning 
the child and a cessation of all demands upon the breast will insure 
relief. Every effort should be made in milder cases to avoid this 
dernier ressort. At first, scrupulous care ; pencillings of fissures 
with a crayon of silver nitrate or the tincture of myrrh ; gentle 
anointings with emollient zinc, thymol, or carbolic acid ointments, 
which should be carefully washed off before the child is put to the 
breast ; and, finally, dusting powders, with soft lint retained between 
and beneath the breasts, are measures to be tried. Later, the subli- 
mate solutions, diachylon ointment, or naphthol, two per cent, in 
alcohol, may be employed. Veiel recommends the application to all 
fissured nipples of Lister's borax salve : 

B . Acid, boracic. subtil, pulv. ) - - 

Cer* alb. J aa gr " xv; 

Paraffin. ") .. _ 

01. amygdal. / c 3SS; M. 

Fournier recommends a breast-plate of caoutchouc. When limited 
to the nipple and areola in nursing women, the glass and rubber 
apparatus sold in the shops may be tried in the hope of saving the 
nipple from the mouth contacts in nursing. Sometimes they answer 
admirably ; often they fail utterly. 

Paget's disease of the nipple should be treated as a carcinoma, and 
may eventually require removal of the breast. 

Eczema of the Umbilicus. [E. Umbilici.] 

This local variety of the disease is briefly described in the chapter 
devoted to seborrhoea. In most cases it is either induced or aggra- 
vated by a local seborrhoea fluida, which gives origin to the peculiarly 
nauseating odor characterizing the disease. Generally a reddish and 
infiltrated, more or less annular patch surrounds the umbilical 
depression, which may be filled with crusts. Syphilodermata, pedi- 



LOCAL VARIETIES OF ECZEMA. 359 

culosis, and scabies in women are to be carefully excluded in the 
diagnosis. The liquor sodse chlorinatse, carbolic acid solutions, and, 
in chronic cases, iodized phenol will be required in its management. 
Care should be taken that the dressing of the navel in the newly 
born infant, the improperly adjusted apparatus for retention of an 
umbilical hernia, and the corsets or " uterine supporters" of women, 
do not occasion or aggravate the disease. 

Anderson reports that in typical cases, especially of those affected 
with scabies, the navel is swollen and projects in the form of a small 
tumor. 

Eczema of the Superior and Inferior Extremities. 
[E. Membrorum. E. Crurale.] 

The flexor surfaces of the extremities, especially in the vicinity of 
the joints, are particularly prone to exhibit symptoms of the disease. 
With these should be properly included the axillary and inguinal 
spaces. In all such localities the alternate tension and relaxation of 
the integument serve when the limbs are in motion, to increase the 
pruritus, and, correspondingly, to aggravate the disease. Often a 
certain degree of symmetry can be perceived, the two popliteal spaces, 
for example, being simultaneously affected, though each to a different 
degree. The parts most favorable for the complications of intertrigo 
are those nearer the trunk, where the moisture and heat are greater, 
as the groins and axillse, while the elbow and popliteal spaces are 
more frequently dry, exhibiting papulo-squamous ridges in lines at 
right angles to the axes of the limbs, with hypersemic patches on 
either side. 

Upon the legs, where the force of gravity is more potent than in 
other parts of the body, exaggerated forms of eczema are found 
complicated with varicose veins and oedema, with dense infiltrations 
and indurations. In ancient cases the frequent elephantiasic aspect 
is significant, one limb being by several inches larger in circumfer- 
ence than its fellow, covered from knee to ankle with enormous 
patches of eczema rubrum of an intensely angry appearance, moist 
and crust covered ; or dry, glazed, and of a lurid reddish hue ; or 
dry, horny, and ridged with irregular projections surmounted by 
scales resembling the rough bark of a tree; or, again, with or with- 
out oedema, tense, inelastic, seamed with scars of old varicose ulcers, 
and deeply and irregularly pigmented, a condition with great diffi- 
culty distinguished from syphilitic ulceration of the same region. 
At its onset, eczema of these parts may assume any one of its known 
forms. In infants with long clothing, where the lower extremities 
are subjected to a higher temperature than in adults, the vesicular 
and pustular forms are common. The exceedingly obstinate forms 
of eczema of the legs, especially those complicated with varicose veins, 
are, of course, those encountered in middle life and advanced years. 

The diagnosis is, in general, to be established by considering the 
points heretofore discussed. The chief difficulty lies in distinguish- 



360 DISEASES OF THE SKIN. 

ing the eczema associated with ancient varicose cicatrices of the leg, 
from syphilitic scars of the same locality which have resulted from 
degenerating tubercular syphilodermata or gummata. In some cases 
when uo distinct history can be obtained, there will be a necessary 
doubt, as the force of gravity upon the vessels, even without vari- 
cosities, produces certain common features, notably deep pigmenta- 
tion, in both classes of cases. In women, the sexual history is all- 
important, including the order of abortions, miscarriages, and viable 
infants. In both sexes, the discovery of other lesions, and especially 
of characteristic cicatrices elsewhere, must be attempted. It will be 
remembered that the syphilitic nicer tends to the shape of a circle 
or segment of a circle, and though occasionally existing as the sole 
lesion upon one leg, it is frequently multiple, or may involve both 
extremities, the pigmentation in old cases occurring chiefly at the 
periphery of the scar. Very extensive pigmentation about ancient 
cicatrices, especially disposed between irregularly defined scars, is 
truer of eczematous forms, as the pigmentation due to syphilis, though 
long-lived, is yet the more ephemeral. With periosteal nodes the 
diagnosis is clearer. 

The dressing best adapted for the larger number of cases of eczema 
of the lower limbs is, after disinfection of the surface and the appli- 
cation of a Lassar or other well selected unguent or paste, the dusting 
of the whole surface, finally, with boric acid. Over this may be 
neatly applied, if desirable, a cheese-cloth bandage. Often, however, 
this may be dispensed with, as in both sexes a woman's long stock- 
ing may be drawn over, made of thin and light material such as is 
used in the summer season, and always of white or undyed cotton. 
Over this stocking may be applied, for the purpose of support, 
either a flannel bandage cut on the bias, which can be, as a rule, 
applied without especial skill by the inexpert ; or in chronic cases 
that will tolerate it, an elastic bandage, the inner white stocking 
being changed with each dressing. In the case of male patients it is 
often desirable that the man's " sock " be drawn over the long white 
stocking below. In this way support without compression (which is 
the essential point) may be secured. 

The general treatment of eczema of the extremities does not differ 
from that described above, except as regards the indications to be 
met relative to support of the parts, thus counteracting the effect of 
gravity. Excellent results may be obtained by the use of the pure 
rubber bandage, applied immediately next the skin, especially in 
cases complicated by oedema, ulceration, and venous varicosity. The 
method of applying the well-known Martin bandage is generally 
familiar to the profession ; and for details respecting its availability 
in eczema of the leg, the reader is referred to the essay on Eczema 
and its Management, by Dr. Bulkley, of New York, 1 who is enthusi- 
astic in its praises. 

Such treatment, however, deserves only subordinate rank in com- 
parison with the essential rest of the affected limb in the horizontal 

' G. P. Putnam's Sons, N. Y., 1881. 



LOCAL VARIETIES OF ECZEMA. 361 

position. With a grave eczema of the lower extremity, such rest 
should be en forced ; and patients whose limbs have proved rebel- 
lious under the rubber (for such there are) may thus be relieved. 
The local applications to be made meanwhile are those adapted to 
the particular features in each case present. 

To a less degree, the same may be said of the arms. In these 
localities it is rarely necessary to resort to elastic pressure. In all 
cases, however, a neatly applied bandage over the dressings will add 
the effect of pressure and support, and generally contribute to the 
comfort of the patient. A favorite dressing in dry, papular, erythem- 
atous, and squamous patches of the disease, is applied as follows : 
The parts are bathed with hot borated water for several minutes 
till the itching is relieved, and then carefully and thoroughly dried. 
The patch is then completely covered with a dusting powder, which, 
according to the indications of the case, is either emollient, astringent, 
or stimulating. Finely powdered tannin with French chalk or 
boric acid and starch ; or bismuth, zinc, and starch may thus be used. 
Over the whole, strips of cheese-cloth are superimposed. A snugly 
fitting rubber or flannel bandage cut on the bias encompasses the 
whole. The dressing is left in situ as long as it is comfortable, often 
for two or three days, when it can be removed. In properly selected 
cases the itching is relieved, the infiltration reduced, and the patch 
soon loses its hypersemic aspect. Occasionally no other treatment 
will be required. 

Nor should it be forgotten that with care and patience, the starch 
bandage of the leg, the plaster-of-Paris dressing over folds of Canton 
flannel arranged so that it may be removed at pleasure in the manner 
in which it is used by some surgeons in treatment of diseases of 
the joints, these and other immovable dressings may accomplish even 
more in obstinate cases than elastic apparatus. 

For the exudative phases of eczema of the leg, the forms so often 
seen here of eczema rubrum, the gelatin medicated plaster meets the 
indications well. Morrow makes this by adding two hundred and 
fifty parts of glycerin to one thousand of gelatin, and two thousand 
of water medicated with ten per cent, of the oxide of zinc and one 
per cent, of carbolic acid. It may be left in situ several days, and 
furnishes a smooth, elastic, and uniform coating. 

Eczema of the Hands and Feet. [E. Manuum. E. Pedum.] 

No more striking illustration of the significance of the etiology of 
eczema can be adduced than that to be discovered in the hands. By 
these organs mau toils to earn his bread, and the eczema they display 
is their protest against the rude contacts which are thus necessitated. 
Unfortunately, in too many of such patients the imperative necessity 
of bread-winning forbids consent to the best method of relief, viz., 
temporary disuse of these orgaus. The feet may or may not be 
similarly attacked, and for similar reasons. All forms of eczema are 
here seen, erythematous, vesicular, papular, pustular, and squamous, 



362 DISEASES OF THE SKIN. 

involving the entire surface, or limited to the wrists, ankles, inter- 
digital spaces, palmar or plantar surfaces, or one or more digits on 
either face. The motions of the part are so free that fissures are 
common and often exceedingly painful. The itching may be severe, 
and the parts of oue haud or foot extensively rubbed, torn, or abraded 
by the other. Vesicles are more frequently encountered upon the 
more delicate portions of the skin, as over the dorsum and inter- 
digital spaces, while in the denser palm and sole they are represented 
by sub-epidermic points from which by puncture a clear serous or 
cloudy fluid may be evacuated. Usually, however, in the regions 
last named, there is a dry, dead-whitish or hypersemic, uniformly in- 
durated and thickened integument, which may be fissured or produce 
such a tense inelasticity of the surface that the fingers are semi-flexed 
into the palm, or, much more rarely, the toes rendered considerably 
less extensible. 

Circumscribed patches of eczema, with fairly defined outline, red- 
dish in color beneath crust or scale, subacute in course, and accom- 
panied by paroxysmal itching, are of common occurrence on the 
dorsum, and also in the palm or sole. In the latter situation they 
may be traversed by one or more painful fissures, the same being 
true of the dorsum of the fingers and toes. Upon the back of the 
hand, these circumscribed patches are apt to assume an indolent 
course, improving temporarily under appropriate treatment, and be- 
coming aggravated by every exposure to the causes by which they 
were first induced. 

The long list of etiological factors which may here be efficient can 
scarcely be enumerated. Several have already been considered in 
discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions of life, 
as well as of the action of toxicants and dyes, must be remembered. 
Thus printers, bakers, and masons suffer in the hands ; and the 
wearers of dyed stockings, and coarse, ill-fitting shoes and boots, in 
the feet. Because needle-women are often overworked, nervous, pale, 
and thin, their digital eczema, really due to the implements and 
stuffs they handle, has been erroneously attributed to their general 
condition. The poor seamstress starving for sunlight, nutritious 
food, and open-air exercise, may return to her weary routine with her 
eczema quite relieved. 

In the matter of diagnosis, it should be remembered that an eczema 
of the hands may be induced by the Rhus toxicodendron, the disease 
being then liable to a transfer by contact from the hands to the face 
and genital or mammary region. Scabies of the same region is in 
this country rarer than eczema manuum. In scabies the vesicles are 
firmer, more often unruptured, fewer, more isolated, more inter- 
mingled with crusts, pustules, and even bullae, which latter are rare 
in eczema. The discovery of the parasite or its burrows and a his- 
tory of contagion will aid in removing doubt. Abundance of pus- 
tular lesions in young subjects is, however, according to Hebra, most 
commonly produced by the acarus. 



LOCAL VARIETIES OF ECZEMA. 363 

The characteristic burrow made by the parasite, an irregularly 
curved, thread-like, beaded, or dotted Hue, about one-quarter of an 
inch in length, either running at a tangent from the unruptured 
vesicle or across its summit, is proof of scabies only second in value 
to the discovery of the parasites themselves. The occurrence of the 
eruption elsewhere on the body is also to be expected in the last 
named disease, with respect to which it should be remembered that 
the burrow may not be visible, and may be wanting when the para- 
sites are present. Psoriasis of the palms and soles is always accom- 
panied by the presence of patches in other parts of the body, whose 
typical characters should throw light on the local disorder. They 
are dry, nou-discharging lesions, very rarely fissured as is the eczema 
of the hands, have a distinct contour, and are covered with more 
abundant and more lustrous scales. The scaling syphilodermata of 
the palms and soles occur early and late in the disease, and usually 
after a distinct history of infection. The lesions in syphilis are 
usually isolated, firm, deep infiltrations, circular iu outline, with very 
sharp definition, and may be covered by dry, adherent, dirty-white 
scales, beneath which the brown and red hue of the persistent lesion 
can be discovered. Superficial or deep circular excavations of tissue 
are visible, single or multiple, with punched or ragged edges. The 
eruption is rarely, like eczema, accompanied by itching or discharge, 
but painful fissures may form. It occasionally affects the dorsum of 
the hand or foot, favorite sites of eczema manuum, but almost inva- 
riably has in such cases swept thither from the palm or from the sole. 

In both syphilis and eczema of the hand, the right organ in right- 
handed toilers is invariably most involved, even where there is 
apparent symmetry of distribution of lesions. 

The treatment demands, first, rest for the orgaus, and a simulta- 
neous discontinuance of the exciting cause. In the trades, the result 
of the latter can be usually demonstrated by the patient, who notices 
the difference between the condition of the skin on Monday morning 
after a Sunday's rest, and that which was distressing on the preceding 
Saturday night. When practicable, protection during labor must be 
secured by the use of gloves, finger-cots, rubber-stalls, or bandages, 
neatly applied and retaining a dressing to the part of the hand or foot 
which is the seat of the disease. For circumscribed, non-discharging 
patches on the dorsum of the hand or foot, the dressing described in 
connection with eczema of the extremities may be applied. When 
the nature of the labor performed is such as to render it impossible 
to secure protection of the hands or fingers in this way, something 
may be accomplished in a few cases by directing that the hand be 
frequently dipped in a protective solution, or powdered during the 
hours of labor. Thus printers may dust their fingers with lycopo- 
dium, and those compelled to retain their hands in irritating solutions 
can anoint these orgaus occasionally with an oily or fatty substance. 
Generally it may be said that an eczema of the hands is too fre- 
quently washed, and the ill effects of such practice are made evident 
not only in laundresses, but in mothers who personally attend to the 



364 DISEASES OF THE SKIN. 

dressing of young infants. The local applications made to each case 
may be those described above as suitable to each stage of the disease. 
When extensively involved, the hand should be carefully dressed, 
each finger being separately wrapped in soft linen rags smeared with 
camphorated or carbolized, pure or diluted, liuimentum calcis in 
acute cases ; or, later, with the Lassar paste, or a bismuth, zinc, or 
mercurial ointment. The tarry compounds are here very useful ; and 
the caustics more than ever needful when there are fissures. The 
latter may often with advantage be painted with the compound tinc- 
ture of benzoin. Protective flexible collodion plays an admirable 
part about the nails where irritable seams and fissures form with 
overhanging fringes of a torn and ragged epidermis, bordered with 
red. In all painful eczemas of this region the immersion, particu- 
larly at night, of the entire hand or foot in hot borated water may 
be practised, followed by careful drying and anointing with a salve 
or an oleaginous semi-liquid. This should be spread thickly upon 
pieces of muslin, wrapped neatly about each finger separately, and 
other affected parts, and the whole covered with waxed paper. The 
Lister protective gauze, or a pair of rather large undyed gloves 
which can be readily drawn over the whole, may be substituted for 
the former. 

When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, by the aid of 
hot water, followed by a salve containing either the white precipitate, 
ten to twenty grains to the ounce (0.66-1.33 to 32.), or the Wilkinson 
tar salve. For intractable cases, caustic potash, in the strength of 
twenty to thirty per cent, solutions, can be mopped well into the 
thickened palm and followed by a salve-application. Van Harlingen 
suggests : 



R . Hydrarg. ammoniat. 


Bj; 


1 


33 


Adipis 


3ss; 


2 




Sevi benzoinat. 


Bvii ; 


10 




01. amygd. dulc. 


tlU; 




66 


Vaselin. 


ad 3vj; 


24 





M. 

For the fingers and hands, Unna's mull plasters, but only if freshly 
imported, fill very perfectly every requirement. These may be cut 
into strips, and applied with neatness to every digit. The zinc oxide, 
tar, and ichthyol mulls are all available for this purpose. 

Eczema as it Affects the Nails. [E. Unguium.] 

There is nothing characteristic of eczema in its effects upon the 
nails. These horny plates participate in the diseases which affect 
their matrices, and thus exhibit nutritional changes. There is, there- 
fore, no eczema of the nail proper, but only an eczema of the digit 
by which the nail is affected. In well-marked cases, one, several, or 
all of the nails of either hands or feet may lose their polish, or 
become rough, punctate, furrowed laterally, and clubbed, or present 
an appearance suggestive of worm-eaten surfaces. They lose their 



LOCAL VARIETIES OF ECZEMA. 365 

uniformly smooth attachment beneath, and become tilted on their 
beds, with marked friability of their tissue. In such cases, an eczem- 
atous condition of the skin at the margin may be detected, where 
the usual redness, infiltration, and scaling, with a sensation of itch- 
ing, point to the nature of the trouble. Rarely the nails are shed. 
The most misshapen will be succeeded by smooth and natural 
growths of nail-substance, if the disease of the matrix be completely 
relieved. The treatment, therefore, is the treatment of the cutaneous 
disease. Care must be taken to exclude ringworm of the nails, which 
end can be reached by microscopically examining the scales scraped 
from the nail-surface. 

The zinc oxide, white precipitate, and tar salves will be found most 
effective for the larger number of cases. Often the organs may be 
with advantage protected during the daytime by the combination of 
gelatin and glycerin described in the management of eczema of the 
extremities, or by rubber cots. 

Eczema of the Tropics (Prickly Heat). [E. Solare. Lichen 
Tropicus, etc.] 

Under these titles has been described a number of disorders, some 
of which are more closely related to the forms of sudamen described 
in connection with the functional derangements of the sweat appa- 
ratus, some of which are instances of papular eczema, associated or 
not with profuse sweating under the influence of high temperatures 
(solar heat, tropical climates, hard labor in the heated air of engine- 
rooms, etc.) The disease is aggravated by all external and internal 
sources of irritation, including alcoholic beverages, opiates, flannel 
and chemically dyed garments worn next the skin, undue exertion in 
a heated medium, fatigue, and obesity. 

Etiology. — The disease is more common in those subjected to rapid 
and intense fluctuations in the temperature of the atmosphere than in 
those long accustomed to a relatively hot climate. It is thus ex- 
ceedingly common in the northern and central parts of our own 
country, where the absence of a regulating Gulf Stream ushers the 
inhabitants suddenly from the rigors of a severe winter to the pros- 
trating heats of summer. It attacks alike individuals of both sexes 
and all ages, beiug often particularly severe in the obese and in 
infants, whose delicate skins, no less than their bowels, resent sudden 
and severe thermal changes. It moreover affects equally those who 
are vigorous and the debilitated. 

The disease is characterized by the occurrence of pin-point to pin- 
head sized vesicles, bright-red papules, vesico-papules, or the two as 
coincident and commingled lesions. They are exceedingly numerous, 
and may in severe cases cover almost the entire so-called non-hairy 
surface of the body, though they may be much more limited in their 
diffusion. They are usually acuminate and discrete, though often 
very thickly set together. They are rapid of occurrence, but may, 
in consequence of persistence of the cause, be slow to disappear or 



366 DISEASES OF THE SKIN. 

recur repeatedly. Whether vesicles be or be not present, the affected 
region is usually bathed in sweat. The eruption is accompanied by 
characteristic sensations of tingling, pricking, and burning; its 
lesions, even though generalized, may be most vivid or most distress- 
ing about the trunk, axillae, head, neck, or extremities. It may last 
for but a few days, or be severe for a week or more. It is un- 
questionably seen in the severest grade among fleshy Europeans or 
Americans emigrating to tropical climates who are habitually ingest- 
ing alcoholic beverages in excess. 

The local treatment of prickly heat is, in brief, that of the cor- 
responding stage of eczema. Unguents are generally to be avoided, 
as the skin rarely tolerates them, and the same may be said of plas- 
ters and very cold baths. Baths or lotions, tepid, warm, or moder- 
ately cool, as the feelings of the patient may decide to be most 
grateful, medicated with alkalies, bran, gelatin, or starch, will be 
found useful. After each, the skin is to be dried, not by rubbing, 
but by gently pressing dry towels over the surface, and is then to be 
thoroughly protected by a free use of one of the dusting powders, 
particularly boric acid and talc. When large tracts of the skin are 
involved, and general baths have been ordered, a package of " corn- 
starch farina " will often be found sufficiently well suited for such 
topical employment. 

Lotions may also be employed, composed of lead, or lead and 
opium, or the black wash, or alcoholic and ethereal solutions con- 
taining camphor and glycerin in the proportions given when con- 
sidering the subject of acute eczema. Modifications of the oleated 
lime-water are serviceable in severe cases, as, for example : 

R 



Sig. 



. 01. lini 


f^ij; 


64 


Paraffin. ") 
Sapon. Castil. J 


aa gij; 


64 


01. bergamii 


q. s.; 


q. s. 


Aq. calcis 


adOj; 


500 


For external use. 







M. 



This makes a demulcent creamy solution which often proves 
exceedingly grateful to the skin ; and to it may be added the zinc 
oxide or dilute hydrocyanic acid, as may be required. 

The general treatment of the patient is a matter of importance. 
The cause must be removed if possible. Withdrawal from the light, 
heat, and labor of the day ; unstimulating food and drink, unirri- 
tating apparel, and rest, are of the greatest importance. The saline 
and acidulated beverages are usually acceptable to the palate, and 
useful if not drunk too cold. The chief value of Apollinaris water, 
lemonade, Vichy, and Kissingen, lies not in their action as medica- 
ments, but as supplying the water demanded by the cutaneous loss 
through evaporation. 

Prognosis. — The disorder may be trivial or severe, and last but 
for a few hours, or for as many months. It is usually relieved 
without difficulty, and often by domestic measures alone. It is most 



PARASITIC VARIETIES OF ECZEMA. 367 

annoying and severe when complicated by the exudative process in 
other parts of the skin than the sweat- ducts and their immediate 
vicinage. 

Universal Eczema. 

In these cases patients should be treated iu bed. The diet is of 
greatest importance and should be of unstimulating quality ; while 
it is not to be forgotten that in a disease involving the entire surface 
of the body the strength is sooner or later apt to be exhausted, aud 
a supporting dietary, even ferruginous tonics, are often required. 

The local treatment is by alkaline and bran baths, followed by 
lime-water and oil lotions ; or preferably by dusting the surface with 
borated starch and talcum, one part of the former to two or three of 
the latter. In treating universal eczema the entire surface does not 
usually require the same topical agents. Often there should be cold 
cream salve, freshly made, for the lids ; a dusting powder for the 
non-discharging or scaling surfaces ; a salve or oleated lotion for 
discharging surfaces of the integument ; and special dressings for the 
extremities, the ears, the hands, etc. 

The Parasitic Varieties of Eczema 

all require treatment for the destruction of the parasite productive of 
each. Thus scabies is practically an eczematoid disease due to the 
presence of the acarus ; and eczema marginatum is to be relieved by 
treatment proper for ringworm of the non-hairy parts. Unna has 
lately discovered in cultures from seborrho'ic eczema fifty different 
mucors, twenty varying kinds of penicilliuin, five aspergilli, forms 
belonging to groups of oidium and saccharomyces ; and cocci and 
bacilli, all of which may perhaps exist without injurious effects upon 
the healthy tissues, but some of which may be capable of inducing 
the disorder calling for treatment. 

Dermatitis Repens. — Under this title Crocker describes an in- 
flammatory disease of the skin, usually a consequence of injuries, 
spreading with a marginate border, and, as a rule, beginning over 
the upper extremities. Garden and Nepveu * have described cases 
which Crocker believes to be of the same class. 

The inflammation spreads from a traumatism, eventually produc- 
ing a raw, reddish surface, denuded of epidermis and oozing at seve- 
ral points, the serous exudate also undermining the apparently sound 
cuticle. The disease spreads with uninterrupted steadiness, lasting 
for months, and in one case invading the larger part of an upper 
extremity. 

In another case the extension was from coalescing reddish papules 
which discharged and left thick, dirty-looking crusts. There was a 

i Brit. Med. Joum., Dec. 11, 1886. 



368 DISEASES OF THE SKIN. 

definite margin to the diseased patch. In yet another case the dis- 
ease began with the formation of blisters. 

The disease has originated in cicatrices after amputation of a 
finger, from burns, from the irritation of the feet after walking bare- 
foot on the sand, and from splinters under the nail. Crocker be- 
lieves that the dermatitis results from peripheral nerve irritation, and 
that there is a secondary parasitic involvement of the part. The 
disease seems to be a simple eczema marginatum, using that term in 
the large sense in which it has been explained in these pages, the 
traumatism being simply an initial factor of the process. According 
to the author cited, the diagnosis from eczema depends chiefly upon 
the recognition of the limited outline of the disease, the entire de- 
nudation of the surface, the undermined edge, aud the thinned, shin- 
ing epidermis left after healing. The disease is to be treated as an 
eczema marginatum. 



Prurigo. 

Lat., prurire, to itch. 

Prurigo is a chronic, exudative, cutaneous affection, commonly beginning in 
infancy or early childhood, and continuing through life, characterized by 
the occurrence on the extensor surfaces of the extremities and also on the 
trunk, of minute, pale or reddish, millet- to hemp-seed sized papules, with 
extensive infiltration and intolerable pruritus. 

The term, prurigo, is one of those which in the past have led to 
considerable confusion in the nomenclature of cutaneous disease. In 
England chiefly, it is applied with more or less looseness to disorders 
accompanied by the subjective sensation of itching, such as the prurigo 
mitis, of Willan, and the disease well recognized under the title pru- 
ritus. Prurigo in this loose sense represents a group of disorders due 
either to the invasion of animal or vegetable parasites, to disorders of 
internal origin, to the ingestion of drugs, or to the other causes de- 
scribed under pruritus. 

The title prurigo is in this work strictly limited to the disease to 
which the name was originally given by Hebra, a disorder beginning 
in earliest life and continuing throughout its duration. It is the 
prurigo ferox, of some authors. Once observed only or chiefly in 
Austria, it has now, in consequence of extensive immigration to this 
country, been seen in America. Several patients from Vienna have 
been presented at the author's clinic. 

Symptoms. — Mild and severe forms of the disease are distinguished 
under the terms Pktjkigo Mitis and Prurigo Ferox, or Agria. 
Incessant care, judicious treatment, climatic influences, and the com- 
forts of life commanded by wealth, seem to determine the difference 
between the two. In both varieties of this affection, pin-head to 
rape-seed sized, firm, whitish or reddish-white papules form, chiefly 
and primarily upon the extensor faces of the extremities, but from 



PRURIGO. 369 

these localities extending gradually over the entire surface of the 
bodv. The itching they produce is of the severest type. 

The earliest symptoms are usually displayed in the latter portion 
of the first year of life, in the form of an urticarial rash, which per- 
sists and is finally succeeded by typical papules. The latter are 
minute, often sub -epidermic, and become rapidly covered with blood- 
stained crusts in consequence of the induced scratching. Then ensues 
a long train of symptoms, including pustulation, fissures, excoria- 
tions, dense infiltrations, crusts formed of exuded serum and dried 
blood, oedema, diffuse dark-brown pigmentation of the surface in 
large areas, and consequent adenopathy. Fully developed, the 
disease presents in general the same physiognomy in different patients 
of different ages. The lower extremities always exhibit the severest 
manifestations of the disease, especially the thigh and leg as distin- 
guished from the foot ; though the trunk, forehead, cheeks, neck, 
arms, and head may be also involved. The protected surfaces, as of 
the axillae and groins, except as regards adenopathy, are free from 
the disease. The general health of the patient manifestly suffers from 
the insomnia and nervous agitation induced by the state of the 
integument. Emaciation, malnutrition, and cachexia are common 
sequelae. The mental and moral tone of the patient thus harassed 
from early childhood throughout an entire life is necessarily pro- 
foundly impaired. Insanity and suicide are reckoned among its 
remote consequences. 

The characteristic lesions first appear about the eighteenth or nine- 
teenth month of life, the urticarial rash up to the second year producing 
merely whitish plaques upon the skin, commingled with excoriations 
and producing a marked degree of insomnia. The minute papules de- 
velop only later on the several regions of preference of the disease, at 
first only appreciable by the touch, later projecting from the surface 
and capped with a blood-scale from the scratching to which they have 
been subjected. Then are to be seen striated excoriations, bulkier 
crusts, pustules, dark, brownish-hued pigmentation, and a rubbing 
off of the hairs such as is often to be appreciated over the brows of 
male patients with erythematous eczema of the face. CEdema, infil- 
tration, and axillary and inguinal adenopathy supervene, so that by 
the end of the second year or the beginning of the third the picture 
of prurigo is complete. At such an epoch the distinguishing marks 
of the disease are its selection of the extensor faces of the extremities 
and the progression of symptoms with added severity from the arms 
to the legs. The natural furrows of the skin are all exaggerated. 
In exceptional cases the lesions are seen over the face and the dorsum 
of the feet. Eczematous attacks may complicate any case. As a rule 
the patient, after maturity has been reached and even old age, pre- 
sents practically the same morbid portrait as in earlier life. 

Prurigo mitis is precisely the same as the severer form of the 
disease as respects the evolution of symptoms ; the only difference to 
be observed is in their intensity. The papules are fewer, the recru- 
descences rarer, the itching less intense, and the amenability to treat- 

24 



370 DISEASES OF THE SKIN. 

merit more pronounced. It is to be noted of all cases that they are 
influenced happily by the warm weather of the summer season, and 
by special attention to cleauliness and hygiene. 

Etiology. — The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. A patient was, however, exhibited at the Inter- 
national Medical Congress in London, whom both Kaposi and H. 
Hebra recognized as affected with prurigo. Wigglesworth, Camp- 
bell, and others, have reported cases in this country. It is needful 
to remember that the term prurigo is here employed to designate the 
disease recognized by some authors as the " true prurigo, of Hebra." 
It should never be confounded with pruritus, which, under various 
usages, may be the title of a mere symptom of a disease. Prurigo is 
more often encountered in the male sex ; is never contagious ; and 
never induced by lice ; but, according to Hebra and Kaposi, may be 
grafted upon an hereditary predisposition. " Scrofula," tuberculosis, 
malnutrition, " misery," poverty, anaemia, and filth, are held to be 
severally favorable to its development. Unquestionably the superior 
resources of the poorest classes in America will long protect them 
from the incursion of this inveterate malady. 

While the typical prurigo ferox, as described by the Vienna school 
of authors, is of such rarity that probably less than a dozen cases 
have been observed in this country, the opinion is gaining ground 
that the same disease with milder manifestations (prurigo mitis) is 
much more common here than has at times been believed. Two 
patients with severe prurigo treated by Hebra himself, found their 
way to the author's clinic with unmistakable symptoms of improve- 
ment after a residence in this country ; and almost every expert in 
America has observed cases of the milder type. 

Pathology. — Kaposi practically admits that, striking as is the 
clinical portrait of this disease, its anatomical features are indistin- 
guishable from severe forms of obstinate papular eczema. The 
microscope reveals merely a hypertrophy of the various elements of 
the epidermis and derma, deposits of pigment in the corium, thick- 
ening of the root-sheaths of the hairs, enlargement of the cutaneous 
muscular elements (erectores pilorum), and a consequent atrophy of 
the integument which has long been the seat of the disease. 

The hairs are thinner, the root-sheaths loosened, and young cells 
are collected in abundance about the follicles. Schwimmer calls atten- 
tion in this connection to the fact that many prurigo nodules are 
pierced with a hair. Auspitz believes that the disease is in fact a 
sensori-motor neurosis without essential lesion. Riehl 1 regards it as 
a chronic form of urticaria. Morison 2 regards the prurigo papule as 
formed by an infiltration beginning around the upper plexus of vessels 
in the corium, which thence spreads to the papillary vessels, enlarging 
the papillae, elevating the epidermis, which at an early stage becomes 
thickened above them. Finally the latter is penetrated, and within 
its strata a vesicle forms, containing serum, blood, and lymph-cells. 

i Archiv. f. Derm. u. Syph., 18S4. 2 Amer. Journ. of the Med. Sci., 1883. 



PRURIGO. 371 

The regions of infiltration about the hair-sheaths and sweat- duets are 
regarded by him as a secondary and not as an essential part of the 
process. The color of the papule does not at first differ from that 
of the skin in the neighborhood, on account of the depth of the 
slight infiltration by which it is characterized, and for the same 
reason it can be distinguished by the touch before it becomes 
visible. 

Diagnosis. — Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, the course of the disease, the 
age of the patient when it is first developed, the great extent of the 
eruption, and the uniform type of its lesions. In prurigo, also, the 
fingers and toes, flexor aspects of the extremities, and face are more 
or less spared. Under treatment eczema commonly yields at least in 
some portions of the skin, while prurigo does not. 

From pruritus, prurigo is readily diagnosticated by its general 
physiognomy and history ; its peculiar pigmentations and infiltrations; 
and by the special region chiefly affected. But both diseases may 
complicate prurigo, especially eczema, which is then ordinarily of 
artificial origin. In pediculosis corporis, the parasites will usually 
be found upon the underclothing, while the lesions induced by the 
nails never form closely packed papules. There is something highly 
characteristic in the widely separated excoriations, puncta from 
wounds inflicted by parasites, and inflamed papules seen upon louse- 
bitten patients. 

In scabies, the characteristic burrows of the parasites will usually 
be recognized, as also vesicular and pustular lesions. Urticaria can 
be mistaken for prurigo only in the earliest stage of the last-named 
disease. 

Treatment — In Vienna, sulphur, naphthol, tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occa- 
sionally served to ameliorate the severe symptoms of the disease. 
Mercury, carbolic acid, boric acid, and the diachylon and zinc oint- 
ments may also be employed upon different portions of the skin when 
indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 
and green soap, has proved of special value in many cases. Vle- 
minckx's solution (q. v.), followed by hot bathing and corrosive sub- 
limate baths, one drachm (4.) to thirty gallons, has also been recom- 
mended. Internally, arsenic has proved valueless, while carbolic 
acid has occasionally seemed beneficial. Cod-liver oil and the ferru- 
ginous tonics with the bitters, will naturally be indicated in many 
patients suffering from malnutrition. A generous diet and tonic 
regimen are essential to the management of most cases, patients 
afflicted with prurigo being usually found in the most wretched 
hygienic conditions. 

Prognosis. — The disease usually persists through life. The most 
favorable conditions are those where the patient is quite young and 
surrounded by circumstances which permit of untiring provision for 



372 DISEASES OF THE SKIN. 

all his needs. Many authors to-day pronounce the disease entirely 
curable in the early years of life. 



Acne. 

Gi\, cm/lit), a point. 

(Varus. Fr., Acne ; Ger., Hautfinne.) 

Statistical frequency in America, 7.34. 

Acne is an inflammatory disease of the sebaceous glands and perifollicular tissue, 
in which appear usually multiple and painful, firm, reddish, pin-head to small 
nut sized nodules, which may result in suppuration and the formation of cica- 
trices. 

Symptoms. — Acne is probably the cutaneous disease of most com- 
mon occurrence, not excepting eczema. The latter affection occurs 
upon the face as often as upon other parts of the body, and is yet 
seen upon the street with far less frequency. Eczema, however, is 
more distressing in its symptoms, and for that reason physicians are 
more often consulted for its relief, the disease thus acquiring a statis- 
tical preponderance. Acne is more tolerable, and therefore more 
tolerated and less treated, especially among the poor. 

The disease is one chiefly occurring in the second and third decades 
of life, and is characterized in general by the occurrence of several 
and usually numerous, light red, dull crimson, or violaceous, pin-head 
to small nut-sized, circumscribed, ill defined papules, nodules, tuber- 
cles, or non-projecting indurations of the skin, often commingled with 
the lesions of comedo and seborrhoea sicca. They are usually both 
slightly painful and tender, though upon this point there is a wide 
range of difference in different individuals, some patients tolerating 
with a surprising equanimity the most extensive invasions of the dis- 
ease. The inflammatory process, which manifestly involves the seba- 
ceous glands and periglandular tissues, may result in suppuration of 
one or several adjacent follicles, as a consequence of which coalescence 
occurs and pea- to large nut-sized, cutaneous and sub-cutaneous 
abscesses may form. In the larger number of cases, however, the 
suppuration is limited to the area of the individual nodule, every 
feature of the entire process being displayed at the same moment in 
an affected individual. Under circumstances of special aggravation, 
the disease may occur in acute forms, but it is commonly chronic; 
and such acute phases are usually accidents of the general process. 

The disease occurs chiefly upon the face, but is seen also upon the 
neck, the back and front of the chest, the genitals, and the extremities, 
the palms and soles alone excepted. It is emphatically a disease of 
the early puberal epoch in both sexes, though occasionally seen in 
middle and later life. It usually lasts, when unrelieved, for years, 
being, during this period, subject to occasional exacerbations and 
remissions ; but commonly spontaneously disappears as the full 



ACNE. 373 

maturity of the body is attained. In severe cases it leaves indelible 
traces of its ravages, in the scars where suppuration has been exten- 
sive. It occurs also in very mild and severe grades. The various 
terms used in the description of the forms of the disease refer chiefly 
to its external features : 

Acne Artificialis. 

Various substances, either applied topically to the skin or ingested, 
are capable of producing acneiform lesions. Among them may be 
named tar, which may prove such an irritant, whether employed 
externally or internally, and, far more frequently, the salts of iodine 
and bromine after ingestion. Tar acne occurs both among workers 
in that substance, and those subjected to its action for the relief of 
other cutaneous disease. Pin-head to pea-sized reddish-brown papules 
then form, at the apex of which is perceptible a minute blackish 
punctum, produced by the lodgment of a minute particle of the 
medicament in the orifice of a sebaceous follicle. Pustular and fur- 
uncular lesions are, however, also produced ; and the same is true of 
brornic and iodic acne. In the latter, Adamkiewicz and others have 
demonstrated the presence of the drug in the contents of the pustular 
lesions. Chrysarobin and a number of other medicinal substances 
are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica 

are terms employed to designate merely the lesion-relics of the dis- 
ease. In the former, there is complete atrophy of the gland-tissue, 
indicated by a minute sunken pit in the site of the former orifice ; in 
the latter there is, in consequence of the periglandular exudation, a 
thickening of the tissues about the acini, and a projection from the 
surface of persistent, pea-sized, and indurated masses. 

Acne Cachecticorum 

includes the symptoms encountered in the subjects of struma, scor- 
butus, marasmus, chloro-ansemia, and tuberculosis. The lesions more 
often develop on the trunk and extremities than over the face, and 
are papulo-pustules, pin-head to bean-sized, particularly indolent, and 
remarkable for their livid, purplish, lurid-red, or violaceous tint. 
The lesions are rarely indurated; more often they are seen as softish, 
pus- and blood-containing nodules, sluggish of career, and leaving 
minute cicatrices. Their features are due entirely to the general 
cachectic condition of the subjects in whom they occur. 

Acne Indurata. 

This is a form of the disease less frequently observed than several 
others, but one which possesses certain distinct clinical features. In- 
duration of the base of the acne papule may be noted in many cases 



374 DISEASES OF THE SKIN. 

of the simple form of the malady ; but in others the glands seem 
generally to be distinguished as minute, very firm nodules, with no 
tendency whatever to suppuration. The surface of the skiu is often 
without marked change in color or heat, the individual lesions 
indeed exhibiting at times an unnaturally whitish aspect. They are 
felt when the finger is passed over the surface as dense, often conical 
projections, occasionally painful, and giving to the touch a sensation 
suggestive of the nutmeg-grater. Comedones may be often dis- 
tinguished intermingled with the papules. The disease, when well 
marked, is apt to be extensive, occurring with characteristic expres- 
sion among brunette, hairy male patients well advanced to the twenty- 
fifth year. It is often generalized over the forehead, cheeks, chin, 
and the back of the neck. 

Acne Papulosa. 

Here the lesions are of a papular type, ranging in size from a 
millet-seed to a coffee-bean, whitish or reddish in color, and varying 
in the amount of firm induration at the base. They are evidently 
due to hyperplasia of the periglandular tissue, and are often com- 
mingled with pustules, papulo-pustules, and comedones. At the 
apex is often distinguished the blackish point characteristic of acne 
punctata, or a minute, greasy, yellowish-white spot, which represents 
the non-pigmented extremity of an inspissated sebaceous plug. 

Acne Punctata. 

In this variety, the acne papule is formed about a comedo. When 
examined, its apex is discovered exhibiting the characteristic blackish 
punctum of that lesion. 

Acne Pustulosa. 

This is probably the most frequently observed of all the forms of 
the disease. The lesions, as usual, are apt to be commingled with 
papules, comedones, and intermediate phases between the functional 
and exudative disorders of the glands. The pustules may be large 
or small, containing merely a droplet of pure pus, or, when a true 
furunculosis ensues, a teaspoonful or more of the same fluid mingled 
with blood and serum. This may be speedily evacuated artificially 
or accidentally, be absorbed, or remain for a long period of time in a 
species of cyst-like loculus, whence it can be finally expressed. In 
aggravated cases, two or more of these pustulo-furuncular depots may 
coalesce, forming nut-sized abscesses, or, not rarely, become united by 
fistulous tracts, through which there is free communication of the fluid 
contents of two or more chambers. 

Acne Vulgaris 

is a term applied by several authors to the composite eruption which 
is common to many clinical cases. Here the various lesions described 



PLATE II. 




ACNE-KELOID OF THE BACK. 
From a photograph of one of the author's patients. 



ACNE. 375 

above are associated, usually on the face and over the shoulders, each 
in several degrees of development, often in conjunction with the 
scars left by a prior eruption. 

Acne Cornea is considered under the title of psorospermosis. 

Acne Disseminata is a name given by some authors to acne 
vulgaris, the common inflammatory type of the disease described 
above. 

Acne Keratosa is the acne cornee of French authors. In this 
affection cornified masses of sebum distend and project from the ori- 
fices of the sebaceous glands, particularly over the neck, but also over 
the face, trunk, elbows, knees, and other portions of the body. 
There is some doubt whether this disease should be classed with the 
ichthyoses which it unquestionably resembles, or with the inflamma- 
tions of the pilo-sebaeous crypt at the outer part — that at least repre- 
sented by its funnel-shaped opening. Such, according to Leloir and 
Vidal, is the pathological anatomy of the disorder, starting in a cornifi- 
cation of the epidermis of this region, precisely as in keratosis pilaris. 

Keloid-Acne is a name which has been given to an inflamma- 
tory folliculitis and peri-folliculitis, leaving deep infiltrations, usually, 
in the thick epidermis over the neck and back of the trunk, though 
seen also upon the face. Wisps of thick, distorted, and evidently 
altered hairs project here and there from the affected surface. Red- 
dish, and even vascularized nodes, tubercles, and bridges occur at 
irregular intervals, interspersed with rare acne pustules and deep- 
seated, broad, even gigantic comedones. Sclerotic tissue, in brief, 
forms about the site of the acne-process quite like cicatricial keloid of 
the trunk and other situations. 

Acne Parasitica is a term which eventually will be extended 
to include many of the varieties of the disease described above. Some 
of the pustular lesions of acne result solely from dissemination of pus 
cocci originally imprisoned within the follicles and disseminated over 
the face by the finger-nails or other means. The good results obtained 
by an appropriate therapy are often the fruit of a destruction of these 
micro-organisms. 

That some of these lesions are at times infected with the bacillus tuber- 
culosis there can be no question. Not only have tubercle bacilli been 
recognized in the pustules of some forms of acne, but singular degen- 
erative and even ulcerative results have been in rare cases produced, 
not solely due to the ordinary processes distinguishable in acne. 

Unna's Ulerythema Acneiforme probably belongs to the latter 
class; and is assigned in this work to the chapter on cutaneous 
tuberculosis. 

Diekerhoff and Gravitz's Contagious Acne, of horses (horse- 
pox), is compared by Kaposi to contagious impetigo rather than 



376 DISEASES OF THE SKIN. 

human acne. It is characterized by an eruption of flattish, pea-sized 
and larger bullae seated on an inflammatory base, visible over the 
mane, the back, and the shoulders. 

Etiology. — The causes of acne are in mauy cases exceedingly 
obscure and are probably numerous. It is common to describe the 
puberal changes in both sexes as a frequent cause of the disease, but 
one should be slow to regard a physiological crisis as a disease- factor. 
It can merely be asserted with safety that, with the growth of the 
hairs in both sexes at the period of puberty, there is an unusual 
activity of the sebum- producing function, and that this physiological 
is then the more readily perverted to a pathological activity. Need- 
less to say that tens of thousands escape acne who survive puberty. 
The disease, however, is apt to appear first at this time of life, and, 
if not improperly treated, to disappear spontaneously when the full 
maturity of the body is attained. 

Inasmuch also as there is a close physiological connection between 
the genital function and organs, and the appendages of the skin, not 
only in man but in the lower animals (antlers of the stag, plumage 
of birds, etc.), it seems reasonable to conclude, a priori, that the dis- 
turbances of the former may be reflected to the latter. Many facts 
support such reasoning. The effect of castration upon the male of 
many animals is displayed in the appendages of the skin. In the 
same way, perverted sexual instincts and habits, or a poorly regulated 
sexual hygiene, and uterine disease (which is indeed often traceable 
to the causes just named) are frequently associated with an acne. To the 
same category belong the disturbances of the gastro-intestinal tract, 
including constipation, dyspepsia, malnutrition from various causes, 
and the struma, tuberculosis, etc., which are responsible for acne 
cachecticorum. The medicinal agents capable of producing artificial 
acne, either by ingestion or after external application, have been 
already named. 

It should not, however, be concluded that any one of these condi- 
tions can be recognized as efficient in the majority of patients. Many 
cases of acne occur in perfectly .healthy young people of both sexes. 
A careful record of many cases of the disease, preserved upon blank 
forms in which is space for noting irregular performance of function in 
the other organs, will exhibit no ailment common to the larger number. 
In these, therefore, it is proper to believe that the causes of the dis- 
ease are entirely local, such as suffice merely to induce primarily 
alteration in the consistency, quantity, or chemical character of the 
sebaceous secretion, and, either as a cause or result of this, an adenitis 
or periadenitis and subsequently an infection with micro-organisms. 

Apart from the local causes to which reference has been made, one 
should not forget that the use of cosmetics, neglect of soap, or the 
use of the cheaper and irritating varieties ; excessive shaving on the 
part of the young man ; friction from hat bands ; " frizzes," " bangs," 
and dyed veils; too frequent fingering of the face (Wigglesworth); 
improper compression of the neck by tight collars ; and a long list of 



ACNE. 377 

other agencies may prove the immediate or remote cause of the 
disease. It is believed that blondes of both sexes are the more 
frequent sufferers. But this observation may have been suggested by 
the circumstance that in those of light complexion the symptoms of 
the disease are more conspicuous and disfiguring. It certainly seems 
that young brunettes, with thick skins and abundant growth of dark 
lanugo hair, furnish the most obstinate cases. 

The distinct cause of acne is the mechanical irritation set up by the 
inspissation of the secreted contents of the gland. The next efficient 
cause is perversion of the glandular function, in consequence of which 
the secretion is changed in character. Lastly occurs infection with 
pus cocci. 

Pathology. — The microscopical appearances are briefly those of an 
inflammatory process with exudation involving the peri-glandular 
tissue of the sebaceous glands and hair-follicles, and that about the 
common excretory duct. There is the usual vascular engorgement,, 
the multiplication of protoplasm within and without the focus of the 
phlegmou, its metamorphosis into pus often mingled with blood, the 
destruction by suppuration of the sebaceous gland, and often the 
preservation of the hair- follicle, though the latter may also be 
involved in the destructive process. According to Kaposi, there is no 
question that the first stage of the disease is always an anomalous 
performance of secretion or excretion in the sebaceous gland. Visible 
cicatrices rarely result, unless the destruction of the elements of the 
derma surpasses the original limits of the gland itself. Where 
suppuration does not occur, there is generally relief of tension by 
extrusion of the inspissated gland-contents and resorption of the 
plastic or fluid exudate in the periphery. 

Diagnosis. — The typical facies of acne vulgaris is readily recog- 
nized by the characteristic features already described. The reddish 
papules, pustules, comedones, and " lumps " in the skin of the face of 
a young subject ; the evident involvement of the sebaceous glands ; 
the history of a chronic affection destitute of itching and though 
possibly picked, quite unscratched ; the occasional blood-crusts where 
lesions have been squeezed or incised, are all significant facts. The 
pustular syphilide of the face is not only to be differentiated by its- 
share in the history of an infectious disease, but by the occurrence of 
characteristic crusts, its selection, by preference, of the regions about 
the nose and mouth, its evolution in groups, and its sequelae in the 
form of superficial or deep ulcerations. Nevertheless, and this is a 
matter of prime importance as regards diagnosis, simple acne is 
exceedingly common in syphilitic subjects. The iodide of potassium 
is so largely administered for the relief of syphilis, and in so large a 
majority of cases induces its artifical acne, that the latter eruption 
often precedes the evolution of the macular syphilide, and also with 
surprising frequency masks the latter by a commingling of lesions. 
Simple acne is common also among those who are veterans of 
syphilis. Acne does certainly at times resemble variola, and cases of 
the former have actually been mistaken for the latter. In most 



378 DISEASES OF THE SKIN. 

instances, the absence of fever and a brief delay will soon put an 
end to any doubt. 

Treatment. — Acne is an entirely remediable disease iu every case 
properly managed from the first. Scars of ancient ravages of the 
affection are, it is true, indelible ; but even these are smoothed down 
in the progress of time, so that they become yearly less conspicuous 
and disfiguring. 

The internal treatment of acne requires a careful and exhaustive 
study of the special requirements of each individual case. For 
most patients the question of diet is of the highest moment — that 
appropriate for the school-boy and the school-girl, or the adolescent 
employed in factory or on the farm or in domestic labor. 

All well-fed subjects of acne are benefited in a high degree by 
reducing the quantity of food ingested, especially in the item of 
meats. A milk diet, or one composed largely of fish, fruits, and the 
lighter vegetables will usually brighten up the most obstinate cases. 
Confectionery, highly spiced food, pastry, hot breads, and cakes, 
sugars, fried articles, and potatoes are all excluded with great advan- 
tage. In most cases, a great deal will be accomplished by cutting 
down the quantity of food eaten while regulating its quality. Alco- 
hol is generally to be prohibited ; and it is idle to treat a severe case 
of acne in a young male subject who cannot for the time abandon the 
use of tobacco in every form. 

An important consideration, at the outset of treatment of a patient 
affected with acne, relates to any local or internal medication which 
has been previously employed. A very large proportion of all 
patients first claim the attention of the physician after ingesting drugs 
or making topical applications which have decidedly aggravated the 
original trouble. With or without the advice of others, such persons 
have often been engaged for months in swallowing the iodide of 
potassium, " red clover," and various nostrums calculated to il drive 
out" the disease; or in rubbing over the skin equally noxious pro- 
prietary substances. In every such instance the skilled physician 
should delay active treatment of the affection until the artificial acne 
has subsided, and the real condition of affairs can be clearly recog- 
nized. The patient should be directed to discontinue his or her 
former practice, to bathe the affected part in hot water at night, and 
after it is dried to apply any bland unguent. By these simple 
measures alone, many cases can be very greatly improved, and some 
completely relieved. Their simplicity should commend them to 
every reader of these pages. It is a good thing to know what not 
to do. 

The constitutional treatment of acne rests for its success upon the 
discovery of the cause of the disease. Many cases certainly require 
no such management, being entirely relieved by local treatment only. 
A thorough investigation of the habits of living, food, diet, bathing, 
occupation, and bodily functions of the patient, such as is described 
in the chapter devoted to General Diagnosis, is essential at the outset. 

Since dyspepsia and constipation are frequent causes of the disease, 



ACNE. 379 

it is necessary to correct these when present ; also any conditions of 
acidity of the stomach, distention of the transverse colon, or marked 
anaemia. 

Some modification of Starting acid mixture, such as the following, 
will be found suitable for many cases : 



Magnes. sulphat. 


3ij ; 


64 


Acid, sulphur, dil. 


fsij; 


8 


Sodii chlorid. 


3J; 


4 


Ferri sulph. 


gr. v; 




Cardamom, tinct. co. 


f sj ; 


4 


Aq. dest. 


adfgviij; 


265 



33 



M. 



Filtra. 

Sig. A tablespoonful in a tumblerful of water before breakfast. 



Other cathartics, saline and alterative, will often prove service- 
able. 

With the recognition of the several causes of acne, general and 
local, has come a day when few will trust to internal medication 
for its relief. Dr. Walter G. Smith, of Dublin, one of the latest 
and most conscientious of the writers on this theme, places the sul- 
phide of calcium, long highly esteemed in the management of acne, 
"side by side with the ludicrous specimens of therapeutic empiri- 
cism/' Arsenic, however, is highly recommended in acne papulosa, 
by both Duhring and Taylor. The internal employment of ergot 
in full doses for the relief of acne has been followed by excellent 
results. Cod-liver oil, iron, the mineral acids, and the bitters are 
needed in chlorosis and cachexia. 

Glycerin in teaspoonful to tablespoonful doses three times daily 
has proved valuable (Gubler). The mineral waters, Hathorn, Hun- 
yadi Janos, oftener Racoczy or Kissingen, a tumblerful before break- 
fast, are exceedingly valuable in cases of habitual intestinal torpor. 
When there is an acid form of dyspepsia, the rhubarb and soda 
mixture, or the acetate of potassium in half-drachm doses (2.), will 
be serviceable. 

Temperate gratification of the sexual instinct in a happy marriage 
is conducive to good results ; and such a condition should generally 
be recommended as favorable for the future of young adults. 
Uterine disease should receive proper treatment when such compli- 
cation exists ; and this, far less by topical applications, than by 
attention to the general health, as the patients of this class are more 
often chlorotic young women with menstrual derangements, leading 
sedentary lives, or overworked at the school-desk, the sewing- 
machine, or the shop-counter. 

In all cases, w T hether previously treated or not, which have been 
purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed, lies the key to success. It is not the selection of one of the 
several remedies of the many advocated for the relief of the disease, 
nor yet the successive substitution of one for another to meet any 
transitory indications in each case, which conduces to the happiest 



380 DISEASES OF THE SKIN. 

result. It is rather the use of a single method of recognized value, 
and its skilful adaptation to the changing conditions of the disease. 

The most important of the methods of local treatment is without 
question the daily sponging of the entire surface of the body (with 
exception of the face and excluding the menstrual period in women), 
in water as cool as can be tolerated, by rapid sponging followed by 
brisk friction with coarse towels or the flesh-brush till the skin is 
glowing. In many cases the author adds common salt to this bath 
in the strength of one quarter of a pound of common salt to each 
gallon of water. The results of this bath are incomparably great in 
many cases, especially where patients have been accustomed to the 
hot or Turkish bath, which is detrimental to affections of this class. 

Next after in importance is to be named the curetting of the 
lesions as practiced by Dr. Fox, of New York. A ring curette is 
drawn over the surface so as to express the contents of the lesions 
and stimulate others to activity. The subsequent bleeding is encour- 
aged by sponging with hot water. All comedones are expressed, and 
the subsequent treatment is that suggested below. 

It is always necessary to evacuate the contents of pustules, to 
express from the summits of papules, where are the orifices of seba- 
ceous ducts, all densely inspissated plugs of sebum, and to remove 
any comedones which are present, by the aid of the comedo-extractor. 
For the purpose of opening the superficial and smaller purulent col- 
lections, the long needles used by gynecologists are decidedly prefer- 
able ; and for the larger and deeper furuncular lesions, a bistoury 
with a delicate and very narrow blade. A slight degree of skill will 
here repay the operator. Piffard's acne-lance is useful in this same 
connection, as is also Volkmann's spoon as modified by Auspitz, 
which may be employed in removing pathological debris. By counter- 
depression with the fingers the whitish-yellow or blackish orifice of 
the duct may be detected, and at that point precisely the needle or 
bistoury should be thrust sufficiently deep to insure the removal of 
pent-up pathological accretions. Should blood flow in droplets from 
any of these slight wounds, it is rather to be encouraged than re- 
pressed, as relieving the hyperemia and engorgement of the small 
peri-glandular phlegmon. In one or several sittings, all lesions 
requiring such interference should be carefully attacked, and imme- 
diately after each, preferably while the pus and blood are still oozing, 
the part is to be bathed for several minutes in water as hot as can be 
borne with comfort. For many reasons, the hour before retiring is 
preferable, though not always practicable, in treating such cases, as 
then a bland ointment can be thoroughly applied and permitted to 
remain till the following morning 

When one or several of such operations have completely relieved 
the skin of its engorgement and retained inflammatory products, a 
systematic use, at night, of the spiritus saponis viridis with hot water, 
should be for a time practised. Let it be noted here, however, that 
many cases which do not require the minor surgical operation 
described above, should be from the first treated in this manner. 



ACNE. 381 

As the face is the most common seat of the disease, it may be, for 
the purpose of description, considered as the affected part. 

The patient is seated before a basin of water, as hot as can be 
tolerated with comfort, and with a pad of white flannel or soft 
sponge, bathes the face till the skin is thoroughly moistened and 
softened by the heated water and steam. From ten minutes to half 
an hour may be well employed in this way, and it is a fertile source 
of the improvement which follows. Then, while the face is still wet, 
all pustules which have formed are emptied, and a sufficient quantity 
of the spirit of green soap is poured over the flannel or sponge, and 
the face thoroughly scrubbed with it. Finally the surface is cleansed 
with a surplus of the water, carefully dried, and anointed with a 
sulphur ointment. 

Some range may be observed in the employment of the two articles 
named. Thus the spirit may be diluted with cologne or rose-water, 
one-half or more ; or the soaps employed, in less imperative cases, 
may be the best toilet, Sarg's glycerin, or sulphur soap. The oint- 
ment, too, may be compounded by adding half a drachm to two 
drachms (2.-8.) of the flowers of sulphur to the ounce (32.) of cold 
cream or vaseline. In the morning, the face is to be washed with 
cold water. 

This operation of steaming, soaping, and anointing, is to be con- 
tinued, according to the severity of the case and the tolerance of the 
patient, nightly, twice in the day, or on alternate nights, till the face 
is free from papules and other inflammatory lesions. At this time 
it is usually unsightly, reddened, slightly tumid, and often moderately 
furfuraceous, but free from acneiform lesions. To the patient, it feels 
tense, slightly painful, and as if made of leather. This accomplished, 
the spirit, or other preparation of soap may be for the time discon- 
tinued. The improvement which follows is marked and speedy; 
and usually quite satisfactory to the patient. When this is reached, 
a wider latitude of treatment is permitted. 

Gradually the hot ablutions may be withdrawn, and the use of 
lotions and ointments other than those containing sulphur may be 
advised. The last-named substance, having the highest reputation 
in the disorders of the sebaceous glands, is a constituent of many of 
the lotions thus employed. 

Taylor 1 advises the following : 

R, 



Sulphuris loti 


3nj; 


12 


Camphorse spts. 


f^iij; 


12 


Sodse biborat. 


3y; 


8 


Glycerin. 




24 


Aq. fontan. 


ad f ^ iv ; 


128 



M. 

Sig. Shake well and apply freely, leaving a thin film of powder over the 
face. 

Various combinations of sulphur with alcohol will be found useful. 
Thus Kaposi recommends a paste composed of : 

1 Arner. Clin. Lectures, vol. iii. No. 10, New York, 1878. 



382 



DISEASES OF THE SKIN. 



R . Sulphur, preecip. 3 ijss ; 10 

Spts. vin. rect. fjjjss; 48 

Lavand. spts. f 3 ijss; 10 

Glycerin. Tll^x ; 1 

Sig. To be spread over the face and retained during the night 



M. 



Or, 



li . Sulphur, flor. 
Spts. sapon. virid. 
Lavand. tr. 
Peruv. bals. 
Camphor, spts. 
Bergamot. ol. 



Sig. To be applied over the face at night. 
Duhring recommends the following : 



3 ijss; 
f^ij; 

TTUv; 
tTlv; 



M. 



R . Sulphur, prsecipit. 
Glycerin. 
Alcoholis 
Aq. calcis 
Aq. ros. 
Sig. Shake the vial before using. 



3ij; 
f.sij; 
f Sj ; 

f^ij; 



M. 



ix; 


288 


;xi; 


192 


Sj: 


32 



Occasionally the rumex ointment may be used with advantage as 
the basis of sulphur and other salves in acne. It is prepared accord- 
ing to the following formula : 

R . Kum. crisp, rad. |j 

Adipis 3 

Cerse flav. 

Aq. pur. q. 

Wash and bruise the roots ; boil for two hours ; strain ; evaporate to four 
ounces (128.) ; gradually add the wax and lard in a melted state ; and stir 
till cool. 

The English hypochloride of sulphur, in ointments of the strength 
of those given above, and the sulphuret of potassium, half to one 
scruple (0.66-1.33) to the ounce (32.) of lotion or ointment are 
effective, but objectionable on account of their odor. 

Various cosmetic ointments will be found useful in superseding 
those described above, as the case progresses. Among these may be 
named, the oxide of zinc, the subnitrate of bismuth, and freshly 
levigated calamine in the strength of from one-half to one drachm 
(2.-4.) of one or more of these substances to the ounce (32.) of cold 
cream salve, to which, as required, the tincture of benzoin, glycerin, 
oil of roses, or bergamot, may be added in suitable proportion. 

For mild cases an excellent lotion is obtained by adding a drachm 
each (4.) of the simple tincture of benzoin and glycerin to four 
ounces (128.) of distilled water, to which, where a more stimulating 
effect is desired, an ounce (32.) of Cologne water or rectified spirit 
of wine may be added, or a scruple (1.33) of the sulphuret of potas- 
sium. The following is the formula of the " Oriental Lotion," 
according to Hebra : 



M. 



Hydrarg. chlor. corros. 


ft] ; 


4 


Aq. destill. 


3iv; 


16 


Ovorum iij albumin. 






Succi citri 


Sgj ; 


12 


Sacchari 


ij; 


32 



ACNE. 383 

The bichloride of mercury is very generally employed in the 
strength of from one-eighth to one-half a grain (0.008-0.033) to the 
ounce (32.) of emulsion of bitter almonds as a lotion ; and the prot- 
iodide, biniodide, and ammonio-chloride of the metal are similarly 
applied in both lotions and unguents ; the first two, in the strength 
of from five to ten grains (0.33-0.66) to the ounce (32.) ; the last- 
named, in the strength of from a half a scruple to a scruple (0.66- 
1.33). One should be careful not to make use of the mercurials at 
the same time with a compound of sulphur, lest a chemical combina- 
tion occur by reason of which the sulphuret of mercury is precipi- 
tated upou the skin and produces the appearance of comedo. Heitz- 
mann highly recommends the solution of Vleminckx. 1 

Kaposi recommends also mercurial plaster applied on strips of 
linen in obstinate cases, for which may be substituted iodated glyce- 
rin (five parts each of pure iodine and the iodide of potassium to ten 
of glycerin), applied with a brush twice daily till from six to twelve 
applications have been made. 

Van Harlingen employs one drachm each (4.) of the sulphuret of 
potassium and sulphate of zinc to four ounces (128.) of rose-water. 
Fox applies half a drachm (2.) of chrysarobin to the ounce (32.) of 
collodion. Taylor advises five to twenty-five grains (0.33-1 .6) of 
the iodide of zinc to the ounce (32.) of vaseline. Veiel employs 
the uncertain unguentum Rochardi : 



R. Hydrarg. chlor mit. 


Bj; 


15 


Iodi puri. 


gr. vij ; 


|5 


Leni igne fusis adde 






Ungt. rosee aq. 


§y; 


64, 



M. 

The paste recommended by Lassar is useful in some cases, that is 
one part of beta-uaphthol, two and a half each of vaseline and sapo 
viridis, and five parts of precipitated sulphur, spread over the skin 
for from fifteen to twenty minutes, and then wiped off, when the sur- 
face is dusted with French chalk. Ointments containing resorcin in 
the strength of twenty per cent, have also been employed with 
advantage, and weak chrysarobin pastes, even though staining the 
face. In obstinate cases with few lesions, the touching of the parts 
with pure carbolic or salicylic acid, or the acid nitrate of mercury, is 
useful, but such measures should be condemned for the majority of all 
patients at or near puberty. A fine needle conuected with the negative 
pole of a galvanic battery may be employed to destroy single and 
indurated papules or papulo-pustules. 

The use of caustics, however, in acne, though recommended by 
several authors, should be in general discountenanced as quite needless. 
In extreme induration of the lesions they may be rubbed with fine 
pumice-stone till the desired effect is produced. 



The formula is : 






R. Calcis 

Sulphur, sublim. 

Aq. dest. 
Coque ad Svj [192.] deinde filtra. 
Sig. " Vleminckx's Solution." 


Sss ; 

sj; 

sx ; 


16 

32 
320] 



384 DISEASES OF THE SKIN. 

The powders employed in the milder forms of the affection, are 
finely powdered sulphur, which may be freely dusted over the face , 
and those compounded, in various proportions, of starch, rice-flour, 
zinc oxide, and the subcarbonate of bismuth. 

In this country relief of acne in young male patients has been 
reported after the passage of the urethral sound and, in both sexes, 
by hot and cold water injections of vagina and urethra. 

Prognosis. — The majority of all patients, even when untreated, 
eventually recover. This natural involution of the disease is com- 
monly attained in proportion as the body arrives at the maturity of 
its development, and accomplishes the sum of its important functions. 
Appropriate treatment has, however, a remarkable and highly satis- 
factory influence in hastening the recovery of a large number of all 
patients. A small minority suffer from the unsightly complications 
and sequelae of the malady (cicatrices, keloid). Exceedingly rebellious 
and even grave cases occur in the cachectic, those long and improperly 
treated, and those who, from necessity, are continuously exposed to 
influences unfavorable to the involution of the disorder, such as the 
subjects of epilepsy habitually ingesting the bromide of potassium, 
and the victims of syphilis requiring persistent use of the salts of 
iodine. 

Acne Rosacea. 

(Rosacea, Gutta Rosea, Acne Rosacea. Fr., Acne Rosee, Couperose ; 
Ger., Kupferrose, Kupferfinne.) 

Statistical frequency in America, 0.634. 

Acne rosacea is a chronic disease of the skin, chiefly of the face, often developed 
from or associated with the lesions of acne vulgaris, characterized by hyper- 
semic maculae, patches of diffuse, dull red erythema, telangiectases, inflamma- 
tory papules, or growths which may attain the size of a hen's egg. 

Acne rosacea is most often displayed upon the nose, though it may 
also affect the cheeks, lips, chin, and, rarely, the lateral regions of the 
neck. 

Symptoms. — In the first grade there is a more or less diffuse and 
uniform, pinkish or dusky, but transitory redness, involving the ex- 
tremity of the nose and its contiguous parts, which may extend from 
this part in a somewhat symmetrical figure over the cheeks and chin. 
The parts give rise to little or no subjective sensation. Under the 
finger, the color disappears under pressure, the surface seems cool 
rather than hot, and the sebaceous glands are seen to be affected, as 
there is usually present either a seborrhoea oleosa or an accumulation 
of yellowish-white, moderately inspissated sebum in the patulous 
orifices of the gland ducts. When the redness has existed for some 
time, minute bloodvessels can be seen ramifying over the erythem- 
atous surface. 

This disorder varies greatly with the general condition of the 



ACNE ROSACEA. 385 

patient. At times it may be scarcely perceptible ; again, after the 
stimulation produced by ingested food or alcohol, after mental excite- 
ment, a paroxysm of coughing or laughing, or exposure to external 
irritation, the lesions may be even conspicuously deforming. This 
may endure for mouths or years, and then disappear or be succeeded 
by the second stage of the malady. 

In a second grade of the disease the redness becomes permanent, 
the capillaries dilate passively and appear as conspicuous, tortuous, 
straight or anastomosing lines of reddish color about the nose, cheeks, 
chiu, or forehead. 

Firm, purplish red, painless, pin-head to pea-sized nodules or 
papules often rise from the erythematous surface, and either display 
minute superficial and tortuous bloodvessels in the integument by 
which they are covered, or project from a base about which such a 
telangiectasis has been very irregularly developed. The lesions are 
apt to be intermingled with those of seborrhcea oleosa or acne vul- 
garis. When fully developed, this stage of the disease, though 
generally not productive of marked subjective sensation, produces an 
exceedingly conspicuous deformity. 

In the third stage, which is the most pronounced of the three, 
roundish, sessile or pedunculated, lobulated or pendulous, firm, 
elastic, pinkish-red, bluish, livid, or violaceous vegetations, traversed 
by finer or larger networks of bloodvessels, slowly develop about the 
affected part of the face, chiefly the nose. These may be single or 
multiple, and in the latter case, isolated, or so closely united as to be 
scarcely distinguishable from each other. The acneiform lesions seen 
in the second grade of the disease, may here also be apparent. In 
other cases, there is a uniform, symmetrical, and elongated hyper- 
trophy of all the soft parts of the nose, which may thus attain colossal 
proportions. It is these consequences of acne rosacea to which the 
term Khinophyma has been applied. 

The course of the disease is very slow, and in by far the largest 
number does not produce the exaggerated types of the second and 
third grades. The lesions may persist indefinitely as indolent symp- 
toms of the malady in any one of its stages, or, in the cases where 
there has been no new growth of vessels or tubercles, proceed to 
spontaneous involution. 

Etiology. — The first and second grades of acne rosacea are common 
in women either at puberty or near the period of the menopause, in 
those who are pregnant, or who suffer from utero-ovarian disease, 
frequent miscarriages, sterility, irregular performance of the men- 
strual function, and chlorosis. It is, however, seen in men of early 
and late adult life. In both sexes it may occur in anaemic and 
asthenic states. In both, also, its association with gastro-intestinal 
dyspepsia, constipation, and the immoderate use of strong tea and 
alcoholic drinks, beer, wines, and spirits, is a matter of common 
observation. According to Kaposi, the rosaceous nose of the wine- 
drinker is bright red ; of the beer-drinker, cyanotic or violet ; of the 
spirit-drinker, smooth, supple, fatty, and dark blue. The new 

25 



386 DISEASES OF THE SKIN. 

growth of vessels and tubercles, with the rhinophyma of the ad- 
vanced grade of the disease, is much more common in men than in 
women. In those whose faces are bronzed by exposure to the 
weather, the telangiectasic condition of the cheeks rather than of the 
nose, is of frequent occurrence. Veteran sailors and soldiers are 
thus commonly affected. Persons who have frozen the nose or the 
cheeks on one or more occasions are similarly liable to the telangiec- 
tasic development. Any externally or internally operating cause 
which tends to retard the capillary circulation in the superficial 
portion of the skin is capable of inducing the result. It is at times 
conspicuously displayed in the mulatto. 

Pathology. — In the first stage of acne rosacea there is merely 
passive hypersemia. The circulation of the blood in the superficial 
capillary plexus of minute vessels is retarded. Persistence of this 
condition for long periods of time results in paresis of the capillaries, 
with their consequent dilatation and hypertrophy, phenomena which 
characterize the second stage, the sebaceous gland disorder being a 
complication of the process. In the third stage, the nodules are 
found to be composed of newly-formed gelatinous elements, which 
become formed by organization. According to Biesiadecki, there 
are also dilatation and hypertrophy of the sebaceous glands, with 
dilatation, hypertrophy, and new growth of the superficial vessels, 
and enlargement also of those trunks which ascend from the corium. 

The disease is viewed, however, differently by authors. By some 
its obvious connection with acne vulgaris is denied. By others it is 
regarded as a seborrhoeal eczema. According to Besnier and Doyon, 
the disease represents : (a) Superficial or deep, at first intermittent, 
then persistent, erythema ; (6) sebaceous erythema, acne-eczema, 
where there is unquestioned steatorrhoea and implication of the 
sebaceous glands with infiltration and possibly exfoliation of the 
skin ; (c) deep erythema with infiltration of the corium and plastic 
products about vesicles, follicles, and perifollicular tissue ; (d) telan- 
giectases, as described above; and, lastly, (e) hypertrophies of the 
perifollicular derma. 

Diagnosis. — Acne vulgaris is distinguished from acne rosacea by 
the absence of telangiectasis, and of the hypertrophic growths which 
characterize the developed lesions of the last-named disease. The 
tubercular syphiloderm is recognizable by its tendency to ulceration 
and crusting, and by the entire absence of telangiectasis. When the 
tubercles of syphilis are limited to the extremity of the nose, and 
are unusually small in consequence of the influence of treatment, 
they often degenerate into characteristic, split-pea sized, irregularly 
circular ulcerations, superficial in seat, aud frequently isolated. They 
leave similarly shaped and sized, depressed cicatrices at the tip and 
neighboring parts of the nose. As the process is much more rapid 
than in acne rosacea, these lesions, considered in connection with the 
absence of telangiectasis, furnish the most significant diagnostic 
symptoms of the disorder, for they often occur late in the history of 
syphilis, in individuals of middle life, and in varying shades of a 



ACNE KOSACEA. 38T 

dull reddish color, circumstances particularly favorable for confusion 
regarding the identity of the two diseases. 

A case of zoster from involvement of the superior maxillary 
branch of the trigeminus, with diffused redness of one side of the 
nose and efflorescence of vesicles over its tip and ala, certainly 
strougly resembles acne rosacea with pustular lesions. Here the 
painful character of the disorder, its limitation to one side, its transi- 
tory career, and its vesicular lesions are sufficiently characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to 
ulceration and crusting, the absence of vascularity, and the frequent 
presence of characteristic cicatrices. Unlike syphilis and acne rosacea, 
however, the history of lupus vulgaris usually extends to early child- 
hood. Lupus erythematosus is yet more readily differentiated, as it 
is not only unaccompanied by vascularization and ulceration, but is 
characterized by scaling and symmetrical diffusion over much larger 
and denned areas, commonly extending from the bridge of the nose 
well on to the cheeks. 

Treatment. — As far as there can be said to be any internal treat- 
ment of acne rosacea, it is that of acne vulgaris, but in neither dis- 
order can such be confidently described as effective in the dispersion 
of the local lesions. The treatment is that of the patient rather than 
of his disease. When alcohol has been in any degree productive of 
the local effects, the use of spirits, wines, and beer is to be inter- 
dicted ; but as regards confirmed rosacea, this will prove to be of but 
little avail. The disease, when resulting from spirit-drinking, may 
persist alter five years of total abstinence. 

The diet should be of the simple character described above as 
proper for the patient with acue. All imbibition of hot liquids, even 
tea and coffee in excess, should be restricted as tending to congest the 
bloodvessels of the face. Everything having the same result in the 
habits, occupation, or clothing of the patient should be, as far as 
possible, deprived of influence, as, for example, the wearing of tight 
collars and corsets, the working over hot fires, etc. 

In many patients who are the subjects of rosacea, as distinguished 
from the younger class of sufferers from acne vulgaris, there are- 
evidences of litha?mia, gout, and similar conditions, requiring even 
stringent rules in many particulars for the conduct of life. The use 
of sugar in many of these cases is to be restricted ; meat should be 
permitted but once in the day ; and other articles of food selected 
with special care. Tobacco should never be allowed to male patients 
with well-marked symptoms, and the daily general bath described as 
of chief importance in the preceding chapter should here also be 
prescribed. 

All gastro-intestinal sources of mischief should be also, when 
practicable, set aside. In acne rosacea, even more than in acne sim- 
plex, dyspepsia and constipation are conspicuously effective factors. 
Here it is well nigh imperative that there be a daily evacuation of 
the bowels. 



388 DISEASES OF THE SKIN". 

Internally, nux vomica, ergot and ergotine, ichthyol (ammonio- 
sulphate), the mineral acids and alkalies, and arsenic have all been 
recommended. Most of these are absolutely valueless, aside from 
local treatment, in removing the symptoms of the disease. In gouty 
patients alkalies may serve to aid the patient, even though not of 
themselves capable of relieving the rosacea ; the same may be said 
of the use of iron in chloro-ansemic women. 

The local treatment of the first grade of acne rosacea is substan- 
tially that of acne vulgaris. Stimulating lotions of green soap, 
alcohol, bichloride of mercury, or sulphur in connection with ablu- 
tions by hot water, are of the highest value. In addition, the various 
ointments containing sulphur, the mercuric oxide and iodides, and 
the continuous application of mercurial plaster should be employed 
if necessary. 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows : 



. Sulphuris prsecipit. 


5J 


Pulv camphorse 


gr. v. 


Pulv. tragacanth. 


.gr. x. 


Aq. calcis "1 
Aq. rosse J 


aa f£j 



32 



33 



M. 



Fox, of New York, applies chrysarobin in traumaticine, half a 
drachm (2.) to the ounce (32.), but this should certainly be reserved 
for intractable cases, as it may have severe results. Even, however, 
after the production of these severe effects, the benefit secured may 
be appreciable for months. 

When the diseased condition is that of the second grade, the indi- 
cation is the destruction of the superficial capillaries, as well as the 
removal of the other indications present. Hardaway, of St. Louis, 
was early in destroying the vessels by single or multiple puncture of 
each with a fine cambric needle attached to the negative pole of a 
galvanic battery, with six to ten elements in the circuit. This is 
better than the knife, which has repeatedly failed. The operation 
may be regarded to-day as the established and effective method of 
removing all blemishes produced by dilated bloodvessels in this stage 
of rosacea. It is simple, readily executed, requires no anaesthetic, 
and is in many ways superior to all other methods, which now should 
be relegated to a second grade in the list as only to be proposed when, 
for any reason, electrolysis cannot be employed. Some vessels may 
be completely destroyed without the production of a cutaneous cica- 
trix which, in the course of a few months, can be recognized by the 
unaided eye. 

For details of this simple and elegant operation the reader is re- 
ferred to the chapter on Hirsuties, where it is more fully described. 
For the cambric needle may often be substituted with advantage a 
fine jeweller's brooch, annealed in the flame of a spirit-lamp. 

The vessels may be entered in one or several places, and the opera- 
tion repeated till the last thread-like evidence of their existence has 



ACNE VARIOLIFORMIS. 389 

disappeared. The number of cells brought into the circuit must be 
somewhat graduated to the requirements of each case and the locality 
of the skin operated upon. Fewer can be tolerated for the lip and 
alse than for the root of the nose, the cheeks, or the forehead. 

Next in value after this operation may be named : 

Brushing the part cautiously with solutions of caustic potash, ten 
to thirty grains (0.66-2.) to the ounce (32.) of water; and the local 
use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, acetum 
cantharidis (Taylor), iodide of sulphur, and solution of the pernitrate 
of mercury. Before any of these, however, be employed, an effort 
should be made to produce exfoliation, by spreading over the part a 
plaster made of green soap. Unna's mercurial plaster-mull is simi- 
larly applied. Kaposi highly recommends the solution of iodated 
glycerin employed by him in acne vulgaris (q. v.), which is painted 
over the part eight to twelve times daily for three or four successive 
days, and immediately covered with gutta-percha paper. 

Multiple scarification of all new growths after the manner of 
attacking lupus nodules ; erasion with the dermal curette, or Braun's 
spoon ; and surgical ablation or decortication of tumors by ligature 
and knife, are also available. After any destructive attack upon the 
diseased portions of the skin, the soothing lotions, fomentations, or 
ointments should be regularly applied. 

Prognosis. — A favorable prognosis can be given in cases where the 
disease is presented in its milder forms. In those complicated by 
marked telangiectasis and hypertrophy, the results of treatment are 
often in the highest degree encouraging. In spite of the most ener- 
getic procedures, however, the vis a tergo of passive hyperemia, in- 
volving often the deeper and unassailed bloodvessels, may work its 
slow progress. For women, the future is in general more promising 
than in the case of men. With the most unfavorable prognosis, 
however, it is to be remembered that, after all, the disease is one of 
deformity rather than of physical discomfort. 



Acne Varioliformis. 

(Acne Frontalis, Acne Rodens, Acne Necrotica, Miliaire Scrofuleuse r 

Acne Atrophica.) 

Acne varioliformis is characterized by the occurrence over the brow, scalp, or 
other regions, of reddish-brown papulo-pustular lesions whose desiccation leaves 
behind a crust that covers a cicatricial depression. 

This disease is not to be confounded with that to which Bazin and 
other French writers once gave the name acne varioliforme, viz., 
molluscum epitheliale (molluscum verrucosum, of Kaposi). 

Symjrtoms. — The disease is characterized by the occurrence over the 
centre or upper portion of the forehead, temples, or margin and cen- 
tral portions of the scalp, of pea- to bean -sized, firm, reddish-brown 
papules which become pustular at the apex, and are commonly indolent 



390 DISEASES OF THE SKIN. 

and often grouped. The pus of these lesions desiccates in crusts 
which are flattish, closely adherent, and apparently depressed below the 
general level of the skin. On the fall of the latter a rather deeply 
tinted brownish-red cicatriform lesion is left, somewhat resembling 
the cicatrix of variola, from which the disease has received its name. 
It much more closely resembles, however, the results of the involu- 
tion of the pustulo-tubercular syphiloderm in groups. The subjective 
sensations are slight, at times there is itching. It tends to recur and 
is exceedingly chronic in course. 

In exceptional cases the disorder occurs in other regions than those 
named above, for example, over the dorsal and sternal aspects of the 
trunk, about the nose, and within and about the concha of the ear. 
The lesions are often traversed by a hairy filament. In some cases 
the affected regions are so thickly invaded that the resulting scars 
produce a cribriform aspect in the integument. Occasionally the 
arrangement of the lesions is linear or circinate. 

The variations displayed are exceptional but worthy of note. 
Severe, confluent, serpiginous, and very extensive developments of 
the malady are seen. According to Boeck, the hue of the papulo- 
pustule is due to minute capillary haemorrhages, which later become 
invisible in consequence of the tumefaction of the overlying integu- 
ment. 

Etiology. — The sexes are represented nearly equally among the 
subjects of the disease who are, as a rule, in or near middle life. 
There is often a history of syphilis, in which event the disease should 
be always classed with the syphilodermata. 

Pathology. — According to Boeck, the local disorder results from a 
hyperplasia of the totality of the epidermis, especially noticeable 
about the external root-sheaths of the hairs, which penetrate the 
corium in the form of somewhat dense cones. The sebaceous glands 
are not noticeably altered in size, the vascular capillaries are com- 
monly dilated and distended with blood, and minute extravasations 
are here and there visible. The pars reticularis of the coram often 
undergoes necrosis in its entire thickness. 

None of the authors touching upon this theme has yet studied 
these troubles from the point of view of tubercle infection. I am 
persuaded that some of these cases are due (as suggested of ulery- 
thema acneiforme in the chapter on tuberculosis) to infection with 
tubercle bacilli. Acne varioliformis occurs in typical development 
upon the faces of the tuberculous. 

Diagnosis. — The lesions are to be distinguished from the syphilo- 
derm named above, from acne vulgaris, and from variola. The 
points of distinction are : the absence of fever present and precedent ; 
the absence of other symptoms of syphilis ; the localization of the erup- 
tion ; and the absence of intermingled comedones and other symptoms 
of acne disseminata. The involvement of the scalp surface is not 
alone sufficient to distinguish it, as the syphilodermata and occasion- 
ally comedones are visible above the brow in the scalp. 

Treatment. — In all syphilitic cases the treatment is that of the 



IMPETIGO HERPETIFORMIS. 391 

constitutional condition. Locally, the use of mercurial and resorcin 
salves; with the application, in severe cases, of caustics, or galvauo- 
puncture is required. 



Impetigo Herpetiformis. 

Impetigo Herpetiformis is a cutaneous disease of women, frequently compli- 
cating the puerperal state, characterized by the occurrence upon the skin and 
mucous membranes of concentrically grouped pustules, and by a febrile con- 
dition which usually terminates fatally. 

Symptoms. — Knowledge of this rare disease is limited to the re- 
ports of thirteen cases observed in the Vienna clinic by Hebra aud 
Kaposi ; one iu New York, by Heitzmann ; one by Pataky ; and a few 
scattered cases recorded by others. Of the Vienna patients, twelve 
were women, and these usually in the puerperal state. 

Pin-head sized pustules, usually closely packed together in groups, 
filled with an opaque or yellowish-green fluid, are discovered upon the 
surface of the groins, navel, axillae, breasts, and other portions of the 
body. A dirty brownish-colored crust is formed by the rupture or 
desiccation of these lesions, and about this, single, double, or triple 
concentric circlets of new and similar lesions appear in succession, 
each series undergoing a similar process of involution. The erup- 
tion thus extends till the circlets from different foci of origin unite ; 
and extensive areas of the skin are involved. Beneath the crusts 
the skin is reddened, infiltrated, smooth, and covered with a new epi- 
dermis, moist as in eczema, or exhibiting a denuded corium. It is 
never in a state of ulceration. In the course of three or four months, 
the eruption is well-nigh universal, the skin being swollen, shining, 
and crust covered, or seamed here and there with excoriations, sur- 
rounded by circles of pustules. The lingual mucous membrane 
exhibits grayish, centrally depressed patches, well-defined in contour. 
Alternate rigors aud febrile accesses mark the periods of recrudescence 
when new pustules form. Delivery seems to have no favorable 
effect upon the course of the disease occurring in pregnant women. An 
endometritis with peritonitis was discovered, post-mortem, in a single 
case. Two women only, of the thirteen Vienua patients, survived; 
and oue suffered from a relapse after several weeks of improve- 
ment. 

The Etiology and Pathology of the disease are necessarily obscure, 
having in view the relatively small number of reported cases. Duh- 
ring describes a much milder malady of similar type, occurring in 
women not pregnant ; and has latterly included impetigo herpetiformis 
in the list of diseases covered by the title, dermatitis herpetiformis ; 
but Kaposi, in the last edition of his treatise, refuses to admit any 
such reduction of impetigo herpetiformis to a class of other maladies. 
Robinson also has described a case supposed to represent one of the 
mild manifestations of the disorder. Kaposi is inclined to associate 



392 DISEASES OF THE SKIN. 

the disease with a pathological condition of the uterus. Heitzmann 
thinks it related to pemphigus. Besner and Doyon conclude the dis- 
ease to have a septicemic origin. 

The Diagnosis of the disease is between herpes, dermatitis herpeti- 
formis, and pemphigus. 

In herpes, the purely vesicular character of the lesious and the 
cyclical career of the disease, indicate its nature. In dermatitis 
herpetiformis there is commonly a distinct multiformity of lesions ; 
and the subjects of the disorder are not, in such great preponderance, 
pregnant women. In pemphigus, the size of the bullae, and their 
distribution in other than concentric groups, will indicate the character 
of the disease. 

The Treatment is conducted on general principles, including the 
administration of antipyretics, and the local employment of alkaline, 
or carbolated baths ; starch and other dusting powders ; anodyne, 
carbolated or simple salves ; and a mixture of plaster and coal-tar. 
The uterus should be relieved of its contents. 

The prognosis is necessarily grave. 



Pemphigus. 

Gr., 7reju(j)^ } a bladder. 

(Pompholyx. Ger., Blasenausschlag). 

Statistical frequency in America, 0.148. 

Pemphigus is an acute or chronic disease of the skin, often characterized by 
febrile and other symptoms of constitutional disturbance, accompanied by the 
production of a series of pea- to egg-sized, oval or spherical bullae, irregularly 
distributed over the surface, and distended with serum or blood. 

With respect to the question whether pemphigus should be re- 
garded as the name of a distinct disease, or of a group of several 
diseases, various opinions are held. At one time every dermatosis 
displaying blebs was accounted a form of pemphigus. With an in- 
creasing knowledge there has been a greater reluctance to distinguish 
any disease, merely because of a bullous exanthem, by this specific 
term alone ; and as a result a number of affections with bullous 
efflorescences upon the cutaneous surface, have been wholly disasso- 
ciated from both pemphigus and what the French term the pemphi- 
goid eruptions. For some authors there is only a chronic pemphigus ; 
for others, in order to establish a diagnosis of pemphigus, the existing 
lesions should repose directly upon the skin without exhibiting a 
peripheral inflammatory areola, or at least be the expression of a 
disease with periodic exacerbations in a determined career. 

In many morbid conditions of the skin bullae are present when it 
is manifestly improper to call the disease pemphigus. For example, 
these lesions are exhibited typically in some forms of lepra, in in- 
herited syphilis, often as a result of the traumatisms of insects, and 



PEMPHIGUS. 393 

of several infective processes. In order to assert that a disease is a 
pemphigus in one of its varieties, it is necessary to recognize the 
presence of other symptoms than bullae. 

The distinctions respecting the bullous dermatoses established by 
Broeq are worthy of recognition. In a first-class are included, as 
suggested above, the bullae which are epiphenomena of some malady 
(e. g., erysipelas). In a second, the bullae are either the main feature, 
or one of the main features of a disease. The second class includes 
both the dermatoses in which the eruptive symptoms are not com- 
monly of bullous type, but which become such under special condi- 
tions (e. g., polymorphous erythema bullosum), and those eruptions to 
which the term pemphigus is assigned by the best authors. 

It is to this last class and to the last named subdivision of the 
class, that the title is assigned in the paragraphs which follow. In 
this group are included (a) Acute pemphigus; (b) Chronic pemphi- 
gus ; (c) Pemphigus foliaceus ; (d) Pemphigus of the newborn ; (e) 
Pemphigus of young girls; (/) Pemphigus vegetans, of Neumann. 

It should be understood at the outset that these are simply clinical 
distinctions of value for the time being. There are doubtless other 
forms of pemphigus, some of which are named below ; and there are 
unquestionably morbid conditions here described, which may be later 
more appropriately classed with other affections. 

Acute Pemphigus. 

The rarity of this disorder has led observers to deny its existence. 
It is however seen, though very rarely, in typical expression, chiefly 
in infants and young adults. I had lately the opportunity of ex- 
hibiting an excellent example of the disorder in my clinic on a day 
when it happened that the President of the American Dermatol ogical 
Association for that year had the opportunity of examining the 
patient with me. 

Acute pemphigus occurs in adults, children, and infants, more fre- 
quently among the very young. It may be epidemic in hospitals 
and other public institutions. With or without an antecedent febrile 
movement, the blebs may appear before birth or within a fortnight 
after, in infants which are either well nourished or cachectic, more 
often the latter. In favorable cases, the evolution of the disease is 
completed in three or four weeks. Any part of the body may be 
affected; but, what is important from a diagnostic point of view, the 
face, hands, and feet are often exempt. The conjunctiva and mucous 
lining of the mouth may, however, become implicated. In some 
cases the pemphigus may be of haemorrhage type. Underneath the 
lesions the rete is exposed, and has a reddish, glistening look. The 
termination may be fatal. Acute pemphigus of adults is still rarer. 
As in the case of infants, there may be marked febrile antecedents 
and systemic disturbance. The eruption of pea- to large nut-sized 
bullae may be sparse or abundant, covering in cases the entire body, 
and attacking the mucous surfaces. The vesicles or bullae may be 



394 DISEASES OF THE SKIN. 

tense, flaccid, and filled with clear, serous, or puriform contents. 
Beneath may be seen a smooth, raw, mucous layer or a diphtheritic 
exudation. According to Weyl, Bulkley's Herpes Gestationis is an 
example of acute pemphigus adultorum. 

The bullae are, as a rule, large, well formed, and irregularly dis- 
tributed over the body, face, and limbs, with acuity of development. 
After a few hours or days crusts form ; the latter, after their fall, 
leaving a slightly pigmented surface beneath. In the case of infants 
the greatest care is required to differentiate the disorder from syphilis, 
commonly not a difficult matter, since the eruptive symptoms in the 
latter disease are first developed, as a rule, at a later period, are less 
acute, and invariably exist upon the person of an infant exhibiting 
the characteristic cachexia of lues. 

Chronic Pemphigus. (Pemphigus Vulgaris.) 

Symptoms. — The term Pemphigus Vulgaris is applied to the 
more common clinical forms of the malady, and has been employed 
generically by many authors to include all varieties of the disease. 
The title Pemphigus Diutinus has also been employed to desig- 
nate that pemphigoid eruption in which the characteristic lesions 
follow each other with rapidity and in profusion, fresh bullae appear- 
ing each day. Fortunately, all forms of the disease are relatively 
rare. 

The cutaneous lesions in this disease are usually preceded by febrile 
symptoms ; and the disturbance of the economy is declared in cardiac, 
respiratory, and gastro-intestinal derangements of function. The 
fever may be continuous, remittent, or intermittent, and is usually 
exaggerated just before the appearance of a fresh crop of blebs. 

The face, trunk, and extremities are chiefly involved. The erup- 
tion first appears bilaterally, somewhat symmetrically, or asymmetri- 
cally, in reddish maculae of rather vivid hue, in the centre of each 
of which appears later a whitish elevation of the epidermis suggest- 
ing a wheal. Either upon these or unaffected points of the skin, 
tense, well-rounded, or oval vesicles developing to bullae subsequently 
form, varying in size from a pea to a hen's egg and even larger, and 
in number from three to six only, to a hundred and more. They are 
usually irregularly distributed (Pemphigus Disseminatus), but 
may be clustered in groups, or very rarely be found the younger 
encircling the older lesions, so as to form a circinate patch (Pem- 
phigus Circinatus) ; their contents are serous, bloody (Pemphigus 
H^morrhagicus), or later purulent, with color corresponding to 
these fluids. They often coalesce, and, whether ruptured or not, 
the involution of the lesion is accomplished by desiccation and crust- 
ing, the crusts being usually found to contain blood, pus, epithelial 
debris, and the exudate from the base of the bleb. Beneath such a 
crust a new epidermis forms, which is usually violet, purplish, or 
bluish-red in color, and, later, displays a brownish pigmentation 
which may for several weeks survive the disease. 



PEMPHIGUS. 395 

Occasionally the affection occurs with very mild and even insig- 
nificant phenomena (Pemphigus Benignus). There may be no 
fever, and a very few blebs appear ; in some cases but a single lesion 
can be seen (Pemphigus Solitarius). In other instances the fever 
is intense ; the eruption abundant ; the skin cedematous, painful, 
pruritic, excoriated ; and the underlying lymphatic glands are enlarged. 
This general condition with exacerbations and remissions may per- 
sist for months, and the eruption then disappear never to return ; or 
to recur, as it often does, in the future. 

Clinically, many of the distinctions between the varieties of pem- 
phigus disappear. Between the benign processes just considered and 
the grave form of pemphigus foliaceus described below, several inter- 
mediate gradations can be observed, and even the most benign may 
at times unexpectedly assume the most malignant phases. Pemphi- 
gus Malignus is a name given generally to those intermediate 
varieties of the disease, most of which are distinguished by persist- 
ent and prostrating fevers ; cachexia, especially in infants ; the 
occurrence of diphtheritic patches upon or about the lesions, with 
infiltration of the derma and slough of its superficial layers ; or 
extensive crusting, and even subsequent ulceration. A form is de- 
scribed by Hebra and Kaposi, in which vegetations and fungosities 
rise from the base of the blebs. 

Pemphigus Pruriginosus is another grave form of the disease, 
in which the lesions give rise to an intense pruritus, under the scratch- 
ing induced by which they are torn, excoriated, and commingled 
with the crusts and exudations of an artificially engendered eczema. 
If the itching be severe, the vesico-bullse may be so torn as to be 
difficult of recognition. Several of these malignaut and intermediate 
forms may terminate fatally. 

In all varieties of the disease the lesions may be exhibited upon 
the mucous membrane of the accessible outlets of the body. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and the period of their efflorescence. There may be a 
week or month of immunity, followed by benign relapses, or by 
malignant and rapid recurrences. The bulla? may form upon an 
unaltered or deeply hypersemic skin, in all sizes from a pea to an 
orange, invading the skin aud mucous surfaces including the vagina, 
the lesions at the base exhibiting the several features described above. 
The eruption is rarely generalized, and throughout not more than 
half a dozen lesions may be at any one moment visible upon the 
surface of the skin. The contents may be removed by evaporation, 
absorption, or rupture, leaving a crust whose color is largely deter- 
mined by the contents of the bleb. 

The areola which may or may not be present in the several forms 
here described, is commonly narrow, aud fully developed only when 
the bleb is mature. The separate lesions may persist for days, or 



396 DISEASES OF THE SKIN. 

rupture at an earlier period, leaving a superficial excoriation behind 
which, after healing, exhibits some pigment. 

The intercurrent disorders in the several forms of disease desig- 
nated may be numerous, death occurring from septicaemia, exhaus- 
tion (especially when the deeper sloughs result, as in pemphigus gan- 
grsenosus), and lymphangitis, the neighboring vessels and glands 
exhibiting evidence of the toxic effects produced by the cocci present. 
In other cases the general symptoms are absent or insignificant ; and 
the subjective sensations limited to a slight feeling of burning or ten- 
sion. In some cases the blebs project completely from the surface 
and are well distended ; in others they are flaccid, the roof partially 
collapsing upon the serous, purulent, or bloody contents. The crusts 
which form are rarely bulky. They are more commonly dark colored 
and thin. 

Pemphigus Foliaceus. 

Pemphigus foliaceus is an exceedingly rare variety of dermatosis, 
which may originate in a grave form of pemphigus chronicus, or may, 
at the onset, present characteristic features. The lesions are flaccid 
bullae, developed without a perceptible pre-existing exanthem, which 
speedily rupture and discharge their ill-conditioned contents, leaving 
beneath an excoriated, reddish or purplish, and at times inflammatory 
surface. Often the blebs are so poorly defined that the epidermis 
seems scarcely raised from the tissue beneath, the condition resembling 
that of the skin to which a blister has been applied, with the result of 
imperfect vesication. The contents, at first pellucid or lactescent, 
become later purulent or sanguinolent. When rupture of the blebs 
occurs, yellowish-brown crusts form which acquire a feeble attach- 
ment to the centre of the floor of the original chamber, while the 
edges remain free ; and these edges, visible over the surface, in poly- 
cyclical or irregular outlines, incompletely hiding the raw and ill- 
conditioned epidermis give a characteristic picture to the skin. 

The disease spreads gradually till it becomes symmetrical and uni- 
versal, a peculiarity which marks it as unique among the pemphigoid 
eruptions, and which, in a sriking degree, distinguishes it from pem- 
phigus vegetans and from pemphigus acutus. As the disease ad- 
vances the patient lies in a pitiably helpless condition, the remaining 
epidermis completely undermined by the serum exuded, in places ex- 
posing large denuded areas of skin in a condition of inflammation of 
a low grade. 

The disease affects the mouth and throat, denuding the mucous 
surfaces of epithelium ; the scalp becomes affected as also the covered 
portion of the body, but the hairs remain attached for a long time. 
Over the face, which was at first merely reddened and scaling, re- 
tractive accidents occur which at times produce ectropion and con- 
sequent conjunctivitis. Over the body, especially at the points 
pressed upon when reclining, profound ulcerations may destroy the 
deep skin. The palms and soles are infiltrated and fissured rather 
than the seat of much exudation. The nails are commonly furrowed 



PEMPHIGUS. 397 

and distorted ; occasionally they are shed. The subjective sensations 
are those of burning, smarting, and soreness, rather than of itching. 
If the patient be kept in the continuous water-bath, though the dis- 
ease be not thereby ended, the comfort of the sufferer is admirably 
secured. 

There may be no fever, or there may be a recurrent rise of tempera- 
ture, and this with recurrence of lesions which in a late stage of the 
disease appear in the sites of those which have been but very im- 
perfectly followed by attempts at repair, a thin and glazed epidermis 
forming in cases of chronic type, where bullae once reposed. The 
disease may accomplish its course in a few months or persist for 
years, and though not necessarily fatal, is unquestionably so in 
the majority of all cases. Death usually results from exhaustion ; 
occasionally, an intercurrent pneumonia or diarrhoea concludes the 
history. 

Pemphigus Neonatorum. 

The disease to which this name is here given should not be con- 
fused with pemphigus acutus, described above, which may occur both 
in the newly born and also in young adults. Pemphigus neonatorum 
is a term which describes an affection observed exclusively in chil- 
dren. The lesions are ill-developed bullae, which appear in cachectic 
infants soon after birth, who have been subjected to the worst 
hygienic influences. The eruption occurs usually about the lower 
portions of the trunk, as these are the regions most requiring, and in 
these unfortunate beings least receiving, care with respect to cleanli- 
ness. In some cases, the children are healthy in appearance and 
suddenly seized with an attack, the skin, according to Fox, becoming 
livid, the bullae surrounded with dark areolae, ulcers forming as a 
result of gangrenous complications. These are probably cases of in- 
fection with the pyogenic cocci in ill-nourished infants, where the 
reaction of the skin is expressed in a bullous rather than in pustular 
efflorescence. The subjects usually perish in a few days, but may 
survive if speedily placed in a hygienic environment. Infants thus 
affected are to be carefully distinguished from those suffering from 
inherited syphilis and exhibiting a bullous syphiloderm on the body. 

An inherited form of pemphigus is described by Goldscheider, Legg, 
and others where several members of one family, upon being sub- 
jected to the slightest external irritation of the integument, suffer from 
a bullous eruption at the site of the irritation. These phenomena are 
said to be most often noticed in summer, spring, or autumn ; rarely 
in the winter. 

Pemphigus of Young Girls. 

This disorder, described by Hardy 1 under the title, " Pemphigus 
"Virginum," is characterized by the appearance upon the skin of oval 
or rounded spots of a reddish or rosy hue, upon which later develop 

1 Traite prat, et descript. des Mai. de la Peau, Paris, 1886, p. 268, 



398 DISEASES OF THE SKIN. 

vesico-bullse of different sizes, which it has been suspected are, in some 
subjects, instances of feigned eruption (q. v.). The subjects of the 
disease are between the fourteenth and twentieth years of life, unmar- 
ried, and usually menstruating irregularly. Others have described 
a pemphigus hystericus to be recognized in hysterical persons of the 
same class, alternating or corresponding with the hysterical attacks, 
the eruptions being irregularly disposed over the surface, and transi- 
tory in duration, disappearing with relative rapidity, and leaving no 
cicatricial traces of their existence. 



Pemphigus Vegetans. 

Neumann 1 was first to describe and furnish illustrations in color of a 
disease to which he gave this name aud which has since been studied 
by a number of observers. Crocker, 2 of London, has published an ex- 
cellent monograph, giving tabulated results in some eighteen cases ; 
and at the meeting of the American Dermatological Association in 
Washington, in 1891, I 3 read a full account of the first case reported 
as such in this country, the patient having been also seen in connec- 
tion with Dr. Duhring, of Philadelphia. 

The onset of the disease is marked by languor, malaise, and ill- 
defined symptoms of poor health, after which the surface symptoms 
may be first declared in the mouth or skin. In the former region, 
white patches which are ill-developed blebs are visible upon the 
mucous surface. The detached membrane forming each spot is 
finally loosened and leaves behind excoriated patches of equal size, 
which produce excessive soreness of the mouth, and which as some 
heal are succeeded by others. In severe cases they render mastication 
and deglutition exquisitely painful ; and in patients where this be- 
comes a prominent feature of the case, the nutrition of the body is 
seriously impaired. 

The skin lesions may precede or follow those in the mouth. They 
are commonly first seen in women about the vulva, spreading over the 
ano-genital region as closely set bulla? covered with a mucoid whitish 
secretion, the features thus strongly resembling the appearance of 
condylomata of the same region. In connection with the mouth- 
lesions, the suggestion that syphilis is present is very striking, and 
has led to this error of diagnosis in the larger number of instances 
reported by those not expert in its recognition. The bullous efflores- 
cences which at first resemble those of other forms of pemphigus, 
speedily exhibit in the site of their production, vegetating masses, the 
change from the bleb to a fungoid papillomatous growth being 
scarcely appreciable. The lesions tend to become grouped about the 
axillae, the circle at the root of the neck, the bend of the elbows, the 
hands, the feet, and the scalp, but have no tendency to become uni- 
versal, even when quite extensive. A singular change in the skin, 

i Vierteljahrschr. f. Derm. u. Syph., 1886, Bd. xiii. 

2 Pemphigus Vegetans (Neumann), London, 1890. 

3 Journ. of Cut, and Gen.-urin. Dis., Nov. and Dec, 1891. 



PEMPHIGUS. 399 

where typical, well-formed bullae have developed and healed, is a deep 
pigmentation in puncta resembling comedones, with pin-point sized 
verrucoid elevations of the surface. In some regions the sequence of 
the closely packed blebs, followed by vegetative masses, resembles 
that seen in pemphigus foliaceus where, especially over the back after 
a long decubitus, large, raw erosions form, exquisitely painful, and 
hastening the patient to the end. The disease progresses in unmis- 
takable accessions of aggravation and improvement, lasting for months 
and occasionally for years. It is, however, in the vast majority of 
all cases, eventually fatal, but one or two of about threescore 
patients having been reported as cured. Variations occur chiefly, in 
the line of the degree of febrile temperature, probably always reac- 
tive ; in the severity of the buccal lesions ; and in the extent of the 
eruption. 

The internal treatment is by roborant measures ; locally, the con- 
tinuous immersion of the patient in water at the temperature most 
grateful to the skin affords speediest relief. The surface is to be care- 
fully dusted with borated, salicylated, and camphorated powders. The 
numerous scalp lesions require cutting short the hairs of that region 
in order to make applications. Alcoholic stimulants are in most 
cases essential. 

Etiology. — The causes of pemphigus are obscure. Yet the connec- 
tion of many varieties of the disease, with changes in the trophic 
nerves and nervous centres, is established by many proofs. It is 
also well known that traumatisms and lesions of the cord have been 
followed by bullous efflorescence upon the bodily surface. At the 
same time, as Kaposi has well shown, on the one hand blebs from 
these demonstrable causes never resemble the portraits distinguishable 
in the varieties of pemphigus ; and on the other, there is no unifor- 
mity among lesions, either as to anatomical site or other features, in the 
spinal changes to be recognized in pemphigus with a fatal issue. 
Further, of nine autopsies of bodies dead of pemphigus, examined 
by the same observer and Weiss, in only one were changes found in 
the cord, (diffuse sclerosis). The view that these dermatoses are in- 
stances of infective trouble is therefore gaining ground ; and it is 
quite probable that future investigations will demonstrate that both 
the cutaneous and nervous lesions are the results of a toxic agency 
operating with morbid results upon each. 

Pemphigus is more frequently encountered in males (and among 
these iu infancy and childhood), because the powers of resistance at 
a tender age are inferior to those of a maturer epoch. The disease 
is often observed in debilitated patients, who are variously described 
as suffering from " nervous prostration," " mental worry and ex- 
haustion," " neurasthenia," "general debility," visceral disorders, and 
impairment of nutrition. In vigorous, rosy-cheeked, strong-limbed 
adults the disease certainly is very rare. Those states in which there 
is marked impairment of bodily vigor are particularly favorable to 
the development of the disease. 



400 DISEASES OF THE SKIN. 

Kaposi relates one history in which the inherited variety of pemphi- 
gus is illustrated, as the patient's mother, sister, mother's brother, and 
some of the children of the latter, had been affected with the malady. 
While, however, this author admits such association of nervous dis- 
order with the disease as occurs in hysteria aud pregnancy, he con- 
cludes that there is little if any etiological significance in the fact. I 
have, however, observed one case in an adult where pemphigus of 
typical appearance occurred after mental depression, which was so 
greatly increased by the appearance of the exanthem as to lead to 
suicide. 

There is good reason to believe that, at least in some of its forms, 
the disease is contagious. The bullous lesions, however, seen in 
syphilis, lepra, and other similar disorders, should not be always here 
included. 

Pathology. — Anatomical changes in the spinal cord (diffuse sclero- 
sis), have been recognized in pemphigus as explained above. Jarisch 
discovered swelling of the processes of the ganglion-cells and inter- 
stitial fibrous deposits in a similar case. Dej£rine and Leloir found 
changes in the peripheral nerves due to degeneration in a case of 
pemphigus. 

The contents of the bullae of acute pemphigus were found to con- 
tain bacteria by Gibier in 1882. The microbes recognized by him 
were, when mature, arranged in chaplets, each containing a series of 
joints. His observations were confirmed by Vidal and Roeser. Riehl, 
in 1883, discovered both conidia and spores in the layer of epidermis 
beneath the lesions of an infantile pemphigus. Demme, 1 in 1886, 
found cocci both in the contents of the bullae, and in the blood. 

On the other hand Thin, of London, 2 after full trial of all methods 
of staining and cultivation now employed, had entirely negative 
results in his attempts to discover micro-organisms in the contents of 
the bullae of pemphigus. 

Diagnosis. — From what has preceded it will be inferred that pem- 
phigus is a name given to a disease, and not merely to bullous lesions 
upon the surface of the skin. It is of some importance to remember 
this fact, as several authors have used the term in a purely descrip- 
tive sense, the fact being that bullae are manifestations of several 
disorders, including syphilis, lepra, pemphigus foliaceus, herpes iris, 
and erythema multiforme. 

At the outset, consequently, the blebs of pemphigus can scarcely 
be differentiated from those of other diseases. It is necessary for its 
recognition that proper consideration be had of all the cutaneous and 
other phenomena present in the disease. In syphilis, such lesions 
are rare in the adult, and relatively more frequent in infants heredi- 
tarily diseased. With the latter, the blebs are usually seen at birth, 
often upon the palms and soles, and are frequently superimposed 
upon an exulcerated base. The coexistence of mucous patches of the 
mouth, vulva, and anus with the evident polymorphism of the lesions 

i Viertel. f. Derm. u. Syph., 1886, p. 636. 
2 Lancet, May 30, 1886, p. 981. 



PEMPHIGUS. 401 

and signs of grave cachexia, will usually indicate the nature of the 
disease. The cutaneous symptoms of such infants are improperly 
designated as pemphigus. Such an eruption is a bullous syphilo- 
derm . 

In the bullae of lepra, there is usually coexisting cutaneous anaes- 
thesia, and the involution of the bleb is followed by a strikingly 
characteristic atrophic patch, usually pigmented and insensitive. In 
pemphigus foliaceus, the extraordinary and usually generalized des- 
quamation which ensues, is sufficiently distinctive, though it must be 
borne in mind, as heretofore stated, that the several varieties of pem- 
phigus may be transformed, the one into the other, by well-nigh 
insensible gradations. Among its graver forms susceptible of such 
transformation may be named, impetigo herpetiformis, pemphigus 
cachecticus, pemphigus diphtheriticus, and pemphigus pruriginosus. 

In herpes iris, the lesions are more vesicular ; much more tran- 
sitory ; subject to a concentric arrangement and variation with respect 
to color ; and are situated more frequently upon the extremities, 
especially the backs of the hands. The bullous lesions occasionally 
seen in urticaria and erythema multiforme are to be recognized by 
the other characteristic symptoms of those diseases ; in the former, 
more particularly, by their intermingling with typical wheals ; and 
in the latter, by the location of the eruption, and its climatic or 
seasonal significance. Some of the reported contagious forms of 
pemphigus, epidemics of which have been described by Besnier, 
Hervieux, and other French authors, were possibly, as Duhring sug- 
gests, instances of impetigo contagiosa. This inference is sustained 
by the frequent allusion of the writers named, to the " varicella-form' ' 
appearance of the lesions. 

In a singularly large portion of cases, pemphigus vegetans has 
been mistaken for syphilis, the close grouping of the lesions about 
the ano-genital region, and their striking resemblance to condylomata, 
taken in connection with the presence of erosions of the mucous mem- 
brane of the mouth, being the grounds for error. With care, this 
blunder can usually be avoided. However closely packed together 
the condylomata of this region, they almost never spread as does 
pemphigus vegetans, beyond the regions adjacent to the mucous out- 
lets ; while the bullae of pemphigus vegetans are not only, when the 
disease is fairly advanced, exceedingly numerous and closely packed 
together, but spread beyond, high toward the pubes and low along 
the inner faces of the thighs. In the latter event, also, there is 
commonly a history of fever ; no lymphatic adenopathy, and a dis- 
tinct uniformity of lesions, each separate element being of bullous type. 

Some of the ingested medicaments are capable of producing bullous 
lesions, for example, the iodide of potassium ; and such a possibility 
should always be borne in mind when establishing a differential 
diagnosis. Scabies in infants and children is occasionally character- 
ized by the formation of blebs, in which case the other lesions present, 
as also a history of contagion and the discovery of the parasite, will 
point to the real nature of the disease. 

26 



402 DISEASES OF THE SKIN. 

Lastly, the external application of cantharides, raezereon, the 
stronger acids, alkalies, and other chemicals, may be followed by 
blebs produced either by accident or intention with a view to feigning 
disease. The intentional production of such symptoms is usually 
effected upon the anterior faces of the lower extremities, regions 
within easy reach of the right hand. Erysipelas and dermatitis 
calorica are also diseases in which blebs appear, always, however, of 
minor significance as compared with the other symptoms of disease 
present. The same may be said of the bullae which form upon a 
gangrenous integument. 

Treatment. — The internal treatment of pemphigus is a matter of 
importance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Mr. Jonathan Hutchinson, 
of London, Eng., in his valuable Lectures on Clinical Surgery, 1 dis- 
tinctly asserts his belief that u arsenic is a specific for the state of 
health upon which relapsing pemphigus depends. " In many years' 
trial of this remedy, he declares that, in his own practice, he has 
never recorded a single failure, though he makes exception, properly, 
of many infantile cases supposed to be syphilitic. The remedy is 
certainly a valuable one, but should be employed with caution and 
in accordance with the rules already prescribed in the chapter on 
Psoriasis. Kaposi, however, declares that he has been unable to 
obtain favorable results from its employment. Iron, quinine, 
ergot, strychnia, and the mineral acids are certainly indicated in 
many cases, in conjunction with a particularly nutritious diet. Cod- 
liver oil and the malt preparations now in the market, should not 
be neglected. 

Not infrequently the treatment should be directed to the relief of 
the anomalous performance of the sexual function in women, as the 
disease has been found to occur in the hysterical and chlorotic states 
sufficiently common as a result of such disorder. 

The local treatment of the lesions should consist, first, in a punc- 
turing of each bleb with a fine needle, in order to give exit to its 
contents, which should be carefully removed from the skin by the 
aid of cotton- wool. Then the parts are to be thoroughly enveloped in 
an inert or borated dusting powder. When there is considerable 
pyrexia with heat and distress in the skin, the surface maybe treated 
as in acute eczema, with oleated lime-water, containing also opium or 
dilute hydrocyanic acid in some such proportions as those already 
detailed. 

The ordinary lead and opium wash, with or without the addition 
of the oxide of zinc, will also answer a good purpose. 

In Vienna, the continuous hot-water bath still enjoys the highest 
favor in the treatment of the grave forms of pemphigus. Kaposi has 
kept one patient day and night for eight months with his body thus 
immersed, to the great advantage of the latter. Such a course is 
often impracticable outside of a large hospital ; but the author has, 

i London, J. & A. Churchill, 1878, p. 49 



HYDROA. 403 

in several cases of grave pemphigus, employed in private practice 
the continuous hot-water bath, with the happiest results. 

Prognosis. — The prognosis in mild cases of pemphigus, though 
much less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the diseases 
heretofore considered, the affection is one not frequently encountered 
in persons of fair general health. The constitutional condition of the 
patient must be carefully considered ; nor should it be forgotten that 
the disease is not only one liable to relapses, but also one in which 
the graver may succeed the more benign manifestations. A flaccid 
summit of the bleb, sanguinolent or ichorous contents, an abundant 
efflorescence, and a rapid succession of new after the involution of 
more ancient lesions, are in general unfavorable symptoms. The 
same may be said of degeneration of the floor of the bleb, after rup- 
ture and discharge of its contents. 

Hydroa. 

Gr., vdap, water. 

The term hydroa was once extensively used as a designation of 
cutaneous disorders characterized by the occurrence of a bullous ex- 
anthem, the blebs being associated with erythematous lesions and 
productive of subjective sensations of itching. It is no longer em- 
ployed by the best authors as a title of disease; and is here set down 
merely in order to enumerate some of the affections liable to be con- 
founded under this title. The Herpetiform Hydroa, of T. Fox ; 
the Dermatitis Herpetiformis, of Duhring; the Herpes Circinatus 
Bullosus, of Wilson ; the Hydroa, of Quinquaud ; the Herpes Ges- 
tationis, of Bulkley, and the Pemphigus Pruriginosus, of Chausit 
and Hardy, are included by some authors under this name. Accord- 
ing to Quinquaud, the essential symptoms of hydroa are a primary 
vesico-bullous exauthem ; a rapid evolution of symptoms; the 
termination of the disorder within two months as a maximum ; the 
occurrence of pruritus in the active periods of the disease; and a 
recognition of varieties, pemphigoid, impetiginous, vesicular, circinate, 
regional, and a form implicating the mucous surfaces. 

Crocker describes a group of diseases by this name, a standing 
midway between erythema multiforme and pemphigus. " The most 
of them, even on the showing of French writers, including Bazin, 
can without difficulty be assigned to the one class or the other. 

Bazin's three varieties, Hydroa vacciniforme, Hydroa vesiculeux, 
and Hydroa bulleux, are instances of either multiform erythema or 
dermatitis herpetiformis. 



404 DISEASES OF THE SKIN 



CLASS III. 

HiEMORKHAGES. 

Cutaneous Haemorrhages. 

Cutaneous Haemorrhage is characterized by the issue of a part or all of the con- 
stituents of the blood from the cutaneous or subcutaneous vessels, with and 
without rupture of the vascular walls. 

Haemorrhage into the skin may be active or passive, idiopathic or 
symptomatic, and may vary greatly in extent. It may be limited to 
but a small area of the integument, or may be symmetrical and 
universal, or coexist with similar blood extravasations in the mucous 
membranes, and the investments and parenchyma of the viscera. It 
may result from undue intra- vascular pressure, as in violent effort 
with extraordinary demand upon the circulatory system. It may 
occur with a normal intra-vascular pressure when there is lessened 
extra-vascular atmospheric pressure, as after ordinary exertion in 
high altitudes. It may result from disease of the vascular walls, as 
in malnutrition. It may occur after traumatism of the latter, or by 
diapedesis through the walls of uninjured capillaries. It may result 
also from lack of support of the vessels due to various disorders of 
peri-vascular tissues, as in the case where the epidermis is artificially 
removed, or where an abscess cavity is evacuated of pus, and the sac 
immediately fills with blood. 

Idiopathic haemorrhage into the skin and neighboring tissue is 
usually the result of traumatism, and accomplished through rent of 
the vascular wall. The discolored patches which result from con- 
tusions of the surface of the body are illustrations of this condition. 
Examples of symptomatic cutaneous haemorrhages are to be found 
in the course of such general diseases as septicaemia and variola, and 
of such cutaneous disorders as herpes, pemphigus, and erythema 
multiforme. 

Bullae H^morrhagicle are globoid, beau- to egg-sized eleva- 
tions of the epidermis, filled with a sanguineous or sero-sanguineous 
fluid, giving such lesions a reddish, brownish, or purplish shade. 

Ecchymomata are nut- to egg-sized, and even larger, firm or 
fluctuating, flattened or elevated tumors, filled with blood, and having 
a cutaneous envelope. 

Ecchymoses are small coin- to palm-sized, and even larger, light 
red to dark purplish, irregularly shaped, macular colorations of the 



PURPURA. 405 

skin, not fading under pressure, and due to circumscribed cutaneous 
haemorrhage. 

Petechia are pin-point to small coin-sized, light red to dark 
purplish macular colorations of the skin, not fading under pressure, 
and clue to circumscribed cutaneous haemorrhage. 

Vibices are linear maculations of various lengths, due to the 
diffusion in the skin of extravasated blood in the form of streaks or 
bauds. They are often commingled with petechia: and ecchymoses. 



Purpura. 

Gr., -opyvpeoc, purple. 

Statistical frequency in America : 0.275. 

Purpura is a disease characterized by the appearance in the skin, of reddish- 
purple or livid maculse, varying in size, usually not clustered, and not wholly 
disappearing under pressure, which may be associated with systemic symptoms 

Some confusion has existed in connection with the term, Purpura, 
in consequence of the fact that it has been employed indiscriminately 
by authors in the designation of both symptoms and diseases. The 
following disorders are commonly included under this title : 

[A.] Purpura Simplex. 

Statistical frequency in America : 0.145. 

In this form of cutaneous haemorrhage, pin-head to pea-sized, light 
red to dark purple petechias and small ecchymoses, usually multiple 
and symmetrical, of slow or sudden occurrence, appear upon various 
portions of the surface, chiefly over the lower extremities, and here 
doubtless by preference, because of the greater effect of gravity upon 
the column of blood. They usually awaken no subjective sensation, 
and may occur in persons of apparently unaltered health, though rigid 
examination will often disclose some facts having a bearing upon the 
etiology of the disease. The subjects of the disorder are frequently 
asthenic, and complain of unwonted lassitude and malaise. The dis- 
ease may last for a fortnight, and in exceptional cases be accompanied 
by a febrile rise of temperature. Lesions of this sort may be due solely 
to an ingested medicament, such as arsenic, salicylic acid (Freuden- 
berg), or quinine. The author has seen the lower extremities com- 
pletely covered with petechias, induced by the ingestion of the iodide 
of potassium, a fact reported by other observers. 

Purpura Urticans 

is that form in which there is an irritability of the skin sufficient to 
produce wheals, urticarial lesions accompanied by itching in various 



406 DISEASES OF THE SKIN. 

degrees, which have the purpuric hue in consequence of circumscribed 
cutaneous haemorrhage. 

[B.] Purpura Rheumatica. (Peliosis Rheumatica.) 

This is a variety of purpura which has a striking analogy to ery- 
thema multiforme, and is probably an exaggerated form of some of 
the conditions recognized under that title. It is preceded by the 
usual febrile or other premonitory symptoms associated with arthritic 
pains, especially of the knees and ankles, which may become swollen, 
or be affected with an hydrarthrosis. In a few days, petechial to 
ecchymotic, light red to dark purplish maculations appear upon the 
extremities, trunk, or the entire surface of the body, fadeless under 
pressure, and usually with coincident relief of the arthritic pain. 
The subjective sensations are ordinarily trivial. In a fortnight, the 
eruption may subside, its color undergoing the usual variations from 
greenish to orange and light yellow ; but relapses are common in the 
course of weeks, with recrudescence of the fever, return of the rheu- 
matoid symptoms, and progressive asthenia. Kaposi describes cases 
in which there was coincidence of purpura rheumatica with renal 
haemorrhage, albuminuria, and gangrene of the soft palate in conse- 
quence of its over-distention with blood. Cases are also on record 
where there w T ere cardiac involvement and grave disorder of other 
viscera. According to Mackenzie, 1 the disease occurs in both sexes, 
more frequently in women however, and between the ages of twenty 
and thirty, though also at earlier periods of life. The purpuric 
spots observed by him usually made their appearance regularly in 
the afternoon or evening, sometimes daily, and often with several 
days interval, accompanied by pain, stiffness, and swelling of the 
joints. The maculae were at first of a bright reddish hue, but 
became purplish by the ensuing day. The site of predilection was 
the extremities, but the eruption in his cases was sometimes more 
generalized. 

The lesions displayed this amount of symmetry : if they occurred 
on one extremity, upper or lower, they would generally be found on 
the other. As a rule, there were no profuse sweats, unless the attack 
occurred with rheumatic fever; the joint affections and pyrexia, though 
distinct, were not severe. Sometimes there was a certain amount of 
erythema accompanying the haemorrhages ; often the eruption was 
purely hemorrhagic. The attacks were frequently protracted, lasting 
even for months, and were liable to recur. 

The disease occurs in both sexes, though more often in young 
women, and is to a certain extent influenced by the changes of climate 
and season. Its diagnosis, in consequence of its marked characteris- 
tics, coincidence of petechia? and ecchymoses with rheumatoid pains, 
is readily effected. Duhring calls attention to the danger of con- 
founding it with the macular syphiloderm, the lesions of which, how- 

i Brit. Med. Journ.. March 18, 1882, p. 383. 



PURPURA. 407 

ever, fade under pressure. The prognosis is in general favorable, 
though the disease may persist for long periods of time, and may, in 
rare eases, terminate fatally. 

[C] Purpura Haemorrhagica. (Morbus Maculosus Werlhoffii.) 

Statistical frequency in America : 0.039. 

This disorder, called also land-scurvy, is usually ushered in with 
phenomena of a febrile character, accompanied by symptoms of 
general depression. Subsequently, ecchymoses appear upon the ex- 
tremities and trunk, both spontaneously and at points where the 
integument has been specially subjected to pressure and friction. 
Usually petechias appear simultaneously upon the nasal, laryngeal, 
buccal, and other mucous surfaces, which may also be the seat of 
exhausting haemorrhages, resulting rarely in fatal collapse. A symp- 
tomatic fever is usually awakened. The disease occurs equally in 
the robust and feeble of all ages, and, though usually as a sporadic 
affection, it may assume an epidemic form. The disease is slow in its 
course, but as a rule terminates favorably after the lapse of several 
months. 

The lesions commonly appear first on the upper extremities ; then 
over the trunk, and finally over the lower extremities. They are 
usually dark red or purplish in hue, varying in size from a pin-head 
to a bean, but may be of the size of the palm. 

It is distinguished from purpura scorbutica, or " scurvy," by the 
absence of distinctive premonitory symptoms of the latter disease, 
and its invariable occurrence among those suffering from improper 
alimentation, vitiated air, and lack of exercise. 

[D.] Purpura Scorbutica. (Scurvy.) 

This disorder is peculiar to those who are compelled to subsist for 
lengthened periods of time on improper food, more particularly that 
from which fruit and fresh vegetables are excluded ; to respire a 
vitiated air ; and to endure such confinement as precludes the pos- 
sibility of duly exercising the body. The disorder is hence more 
common among sailors, prisoners, Arctic voyagers, and men similarly 
situated. 

The cutaneous lesions are, as in so many other forms of purpura, 
preceded by an almost characteristic sense of languor and depression. 
One or several joints may then enlarge. There may be, however, a 
distinct febrile action. 

The haemorrhages which result are quite like those of purpura 
hsemorrhagica ; and the cutaneous lesions are petechias, ecchymoses, 
and painful ecchymomata, usually first appearing on the lower ex- 
tremities, which may fluctuate, open, and result in offensive ulcera- 
tions reaching to the bone. Simultaneously with the cutaneous erup- 
tion, the gums become involved, and show as tumid, haemorrhagic, 
or ulcerative fungosities, smeared with a dirty yellowish secretion, 



408 DISEASES OF THE SKIN. 

and having a fetid exhalation. The subcutaneous connective tissue, 
muscles, fasciae, and viscera become also involved. The disease is 
accompanied by febrile and other general phenomena of asthenia, 
and, when the causes are persistent, results fatally. It is, however, 
remediable by proper treatment, though convalescence is usually 
tediously prolonged. 

[E.] Purpura Pulicosa. 

is the result of the traumatisms produced by fleas, lice, and bugs. 
The lesions are punctiform, and due to the welling up of blood into 
the minute punctured wound, surrounded usually by an hyperaemic 
halo which is the result of the irritation. When the latter fades, 
the central hemorrhagic point usually for a brief time persists. The 
disease is characteristically manifested upon the filthy skins of indi- 
viduals long bitten by bugs, and covered with excoriations and dark 
colored crusts, the result of scratching. Such cases are often pro- 
nounced scorbutic. 

The symptoms of cutaneous haemorrhage are observed in other 
conditions beside those named above. Petechias and ecchymoses are 
also displayed upon the lower extremities of some of the subjects of 
tuberculosis, cancer, and the plague. In Haemophilia, a disease 
occasionally of hereditary origin, and characterized by the facility 
with which trivial traumatisms of the surface are followed by in- 
coercible haemorrhages, purpura may be the first signal of the pre- 
disposition. A young man with purpuric lesions of both lower 
extremities, and otherwise in apparently good health, lately presented 
himself at the Dermatological Clinic for the relief of the difficulty. 
There was at the time no suspicion of haemophilia, but two weeks 
later, as the result of a vaccination, he bled continuously for eight 
days. 

General Considerations respecting the Purpuras. 

The conditions described above under separate titles are, in point 
of fact, merely surface symptoms of different local and systemic 
states. Various classifications have been made of these, the best of 
which are based on analogy with demonstrated facts in similar mor- 
bid conditions. 

1. Primary infectious purpura. Letzerich, in 1889, recognized 
in the spots of purpura hemorrhagica long bacilli, cultures from 
which injected into rabbits produced a species of bacillogenous pur- 
pura with stuffing of the hepatic capillaries by colonies of the same 
micro-organism. The belief is at present gaining ground that pur- 
pura scorbutica and other forms of purpura are infectious disorders, 
the micro-organisms of which have not yet been identified and de- 
monstrated as effective agents in the production of the disease. 

2. Secondary infectious purpura. In this group should be ar- 
ranged the lesions exhibited in haemorrhagic variola (" black measles"), 



PURPURA. 409 

snake-bites, typhoid fever, and other diseases of recognized infective 
origin. 

3. Purpura symptomatic of general non-infective disorders. In 
this group may be included the lesions produced by drug-ingestiou, 
anaemia, leucaemia, and cachexia. 

4. Purpura due to local causes. Here may be classed the lesions 
due to fragments of sarcomata lodged in the vessels of the part 
affected (Fagge) ; to incursions of lice, bugs, etc. ; and to changes in 
the vascular walls due to metamorphosis of the cellular elements. 

Etiology and Pathology — Mauy instances of purpura are either 
primary or secondary results of an infective process due to baeillo- 
genous products. The results of the investigation of this subject 
made by Letzerich, Petrone, Guirnard, and others have been referred 
to above. It is probable that in other forms of purpura, facts of 
similar etiological importance will be established. 

Many cutaneous haemorrhages, not resulting from traumatism, 
however manifestly and immediately due to morbid conditions of the 
vessels, are by many authors believed to have a neurotic origin. 
Purpura haemorrhagica, for example, in consequence of the frequent 
absence of lesions of the vascular walls sufficient to produce its phe- 
nomena, is by Wagner, Henoch, and others explained by supposing 
either abnormal excitation of the sympathetic system, or paresis of 
the vasomotor centres. Cavalier l reports a case of purpura alternat- 
ing with paralytic symptoms. The frequently symmetrical disposi- 
tion of the lesions has received a similar interpretation. Tyrrell 2 
reports cases induced by marsh-miasm, and Satterthwaite, 3 of New 
York, a similar case, in which the eruption followed a chill lasting 
three-quarters of an hour. 

In all these cases, the haemorrhages occur chiefly in the derma, 
though often in the subcutaneous connective tissue, a fact well illus- 
trated by the drawings made by Variot 4 of sections of the purpuric 
skin of a patient dead of haemoptysis. In this case there was nu- 
merical diminution of the red corpuscles in life, as demonstrated by 
the hematimetre, without any change in their form, volume, or color. 
Inflammatory complications in these conditions are rare. The color 
of the several lesions induced is, without question, derived from the 
haematine, which not only stains the environing fluids, but also the 
tissues themselves where the extravasation occurs, and appears, when 
absorption of the fluid portions of the clot has been accomplished, in 
the form of variously sized granules. In this way, the color-chauges 
between red, orange, yellow, purple, and violet in the resolution of 
petechiae and ecchymoses are to be explained. The persistence of the 
pigmentations varies with the quantity of the effused blood and its 
seat. In mild cases, especially of lesions involving the upper half 
of the body, all traces of the haemorrhage may be removed in the 

1 Bull. Gen. de Therap., 1879. 

2 Pacific Med. and Surg. Journ., June, 1876. 

3 Med. Gazette, Jan. 14, 1882, p. 14, cited by Duhring. 

4 Journ. de l'Anatom. et de laPhys., Nov., Dec, 1881, p. 520. 



410 DISEASES OF THE SKIN. 

course of a few weeks. Dark pigmentations resulting from purpura 
scorbutica are, in some persons, perceptible upon the lower extremi- 
ties after years of persistence. 

Wilson, Fox, and others, again, have recognized lardaceous or 
inflammatory changes in the vascular walls, with embolism or 
thrombus in others. Watson Cheyne 1 discovered in a case recorded 
by Russell, some of the capillaries in the neighborhood of the haemor- 
rhages plugged with bacilli, and colonies of the same in the blood 
effused after rupture. 

Treatment — The treatment of these various forms of cutaneous 
haemorrhage will clearly depend upon the nature of the cause in each 
case. In general it may be said that internally the use of ergot, of 
the chloride or other salt of iron, and of quinine is advisable. The 
oil of turpentine, the tincture of the muriate of iron, the acetate of 
lead, and dilute sulphuric acid, have all been employed at times with 
marked success ; at others, without ; in the treatment of these cases. 
Hypodermatic injections of Bonjean's ergotine, one part to two of 
distilled water, repeated every second day, have been speedily fol- 
lowed by favorable results. A generous diet, the use of wines, malt 
liquors, and even spirits, and strict observance of the demands of 
hygiene, are often essential methods of relief. 

In the way of local treatment, the gums often require an applica- 
tion of rhatany, one part of the extract to fifty or sixty of lotion ; 
or equal parts of the tincture of cinchona and tincture of myrrh, 
diluted as required. 

Rest in the recumbent position is advisable, and, if haemorrhage 
be actually in progress, the free use of haemostatics will be required 
with local application of ice. For those who are convalescent from 
systemic disorders accompanied by purpuric lesions of the lower ex- 
tremities, resorption of the extravasated blood may be hastened by 
the local application of stimulating spirit lotions with friction ; and 
the pressure of the blood column may be partly relieved by elastic 
bandaging of the extremities. 

The prognosis has been given, as far as might be, in connection 
with each disorder named. 

i Brit. Med. Journ., Sept. 1, 1883, p. 416. 



LENTIGO. 411 



CLASS IV. 

HYPERTROPHIES. 

1. Of Pigment. 
Lentigo. 

Lat, lens, a freckle. 

(Freckles ; Ephelis. Ger., Sommersprosse.) 

Lentigo is that condition in which occur pin-head to bean-sized, yellowish to 
brownish, circumscribed, and usually multiple maculations of the cutaneous 
surface, due to an excessive deposit of pigment, most often seen on the face and 
dorsal surfaces of the hands. 

Symptoms. — This condition is due to excessive and irregular 
deposit of pigment in the skin, producing the pin-head to bean- 
sized spots of circinate or irregular outline, frequently grouped 
and even confluent, which are commonly designated as " freckles" 
They are most frequently seen symmetrically distributed on the 
parts of the body ordinarily exposed to the light and heat of 
the sun and to atmospheric influences, such as the face, the neck, 
and the backs of the hands in persons of both sexes. In those 
whose bodies are to a greater extent similarly exposed, they occur 
upon the chest, the back, and over the extremities. In other indi- 
viduals, they may be seen upon parts not thus exposed, such as the 
penis, the scrotum, and the inner faces of the thighs, a fact which 
indicates that they are not always the result of the operation of the 
agencies noted above. They vary in color from light yellow, salmon, 
or red to the deepest brown ; and are most noticeable in persons 
having red hair and a delicate skin. They occur rarely in infancy, 
partly, perhaps, on account of the infrequency of out-door exposure 
in tender years ; and are usually seen first about the age of six to 
eight years. They are commonly observed in mulattoes, individuals 
of a race particularly disposed to the anomalies of pigment distribu- 
tion. Once developed, the lesions may persist through life without 
marked alteration ; or fade with each recurrence of the season of 
winter ; or in milder cases, entirely disappear. They usually share 
in the atrophic changes of old age, and when persisting to that 
period, may then spontaneously disappear. They are not the source 
of subjective sensation. 

Etiology. — Freckles are, without question, produced and aggravated 
at times by the action of the light and heat of the sun, as a common 
experience declares ; but it is evident that these forces must act upon 
a susceptible skin. Of a hundred sailors exposed in precisely similar 



412 DISEASES OF THE SKIN. 

situations on a long cruise, some of the number will be uniformly 
" tanned," aud others deeply ft freckled." Attention has been called 
to the occasional occurrence of lentigo in the protected parts of the 
skin. Dr. White, of Boston, in an interesting paper on melano- 
derma, 1 calls attention to the fact that exposure to sea-air and fog, 
with obscuration of the sun, is sufficient to produce the result. 

Pathology. — Freckles are due to an increased deposit of pigment 
in definite areas of the rete mucosum of the epidermis, never in the 
corium. Lesser urges, with strong probability in his favor, that 
there is always a congenital predisposition to these pigment forma- 
tions which requires certain external conditions for development. 

Treatment — The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Prof. Wertheim, of Vienna, 
advises : 

R . Hydrarg. ammon. muriat. gr. lvj ; 3 75 

Bismuth, magister. gr. lij ; 3 50 

Ungt. glycerini gj ; 32 M. 
Sig. To be applied only every other night. 

Bulkley employs : 

R . Hydrarg. chlor. corros. gr. vj ; 4 

Acid, acetic, dilut. f.^ij ; 8 

Boracis "►} ij ; 2 66 

Aq. ros. fjiv; 128 M. 

Sig. To be applied night and morning, at first with gentle brushing ; after- 
ward by rubbing. 

Hardaway touches each freckle with a rather stiff needle connected 
with the negative pole of a galvanic battery, aud finds the results 
satisfactory. 

Most of the secret methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, it 
is evident that the pigment of its cells is also removed with it ; and 
the new epidermis is for a time quite free from blemish. But in 
all such cases the ultimate result is a deeper and more persistent 
pigmentation than that which was previously visible. 



Chloasma. 

Gr., x?toa£G), to possess a greenish color. 

Chloasma is that condition in which occur yellowish to blackish, finger-nail to 
palm-sized, circumscribed, diffuse, and ill-defined maculations of the cutaneous 
surface, due to an excessive deposit of pigment. 

Symptoms. — In this affection the skin is either diffusely discolored 
in various shades, or the maculations occur in patches larger than 
those of lentigo, fairly well-defined, and irregular in contour, the so- 
called " liver-spots." In color they vary from a scarcely perceptible 

i Bost. Med. and Surg. Journ., May 16, 1S78, p. 624. 



CHLOASMA. 413 

staining of the skin, which requires a strong light for its detection, 
to a deep-yellow, a yellowish-green, a chocolate-brown, or a blackish 
shade (Melanodeema). They may be either idiopathic or symp- 
tomatic in character. 

The idiopathic varieties of chloasma are produced by all externally 
operating agencies, in consequence of which an undue afflux of blood 
is persistently determined to any portion of the skin. It is largely 
from the blood that the pigment is derived, and hence the stains 
produced by the latter are, to a certain extent at least, proportioned 
to the hyperemia, stasis, or extravasation of the vascular fluid. 
Among these externally operating agencies may be named, pressure 
and friction (as over the part covered by the pad of a truss) ; trauma- 
tism (as after the severe scratching of the skin affected with lice, 
eczema, or scabies) ; heat (as in diffuse " tanning " of the face, or 
" sunburn " following exposure to the solar rays) ; and the toxic or 
irritating effect of externally applied substances, such as mustard, 
capsicum, cantharides, and other articles capable of producing either 
vesication or pustulation of the surface. The physician should 
always remember the possibility of producing long, persistent, or 
even permanent pigmentation of the skin upon the face, shoulders, 
and bosom of young women especially, by the repeated application of 
such topical medicaments. 

The symptomatic varieties of chloasma are the results of disorders 
either systemic or involving the internal organs. They occur as 
either circumscribed or diffuse, localized or generalized, spots, mot- 
tlings, stainings, or u masks " of the skin ; and vary in color from 
the lightest to the darkest shades. One of the most common, and at 
the same time the most marked of these, is 

Chloasma Uterinum, 

so called because of its frequent association with certain physiological 
or pathological conditions of the uterus, both among married and 
single women. Thus in pregnancy, sterility, hysteria, chlorosis, 
ovarian disorders and tumors, and functional derangements of the 
uterus, there can be observed at times a facial discoloration extending 
equably over the forehead and reaching nearly to the line of the hairs 
at the scalp, in the form of a faiut or decidedly yellowish, reddish- 
yellow, or deep brownish tinge. At other times, the discoloration is 
macular and asymmetrical, involving the lids, the cheeks, the lips, or 
the chin. When the chloasma assumes the mask-like form, it is 
usually most pronounced over the forehead, but may involve the 
whole facial region, being less distinctly defined below than above. 
Similarly, the well-known changes occur in the areola of the nipple, 
along the linea alba, and about the external genitalia. 

Melanoderma, or Chloasma, Cachecticorum 

is another of the symptomatic pigment disorders, characterized by 
the changes in the color of the integument of the subjects of tubercu- 



414 DISEASES OF THE SKIN. 

losis, syphilis, cancer, chronic alcoholism, malaria (e. #., " Chagres 
fever ' ''), and other disorders. 

Addison's Disease, 

formerly thought to be due exclusively to lesion of the supra-renal 
capsules, is of the same nature, and characterized by a peculiar 
bronzing of the skin Overbeck and Greenhow have shown that 
the capsules may be completely destroyed without changes in the 
skin-color resulting. The pigmentation may be general or partial ; 
and in the latter case is without definite lines of demarcation. It is 
commonly most pronounced over the face, neck, scrotum, groins, 
axilla?, and nipple and areola. The hairs become coarse and dark : 
and dark patches are at times visible over the mucous surface of the 
lips, gums, and other parts of the mouth. The bronze or mulatto- 
like color of the skin is intensified by stimulation or erosion of the 
cutaneous surface. In these cases there is generally marked asthenia, 
and a feeble pulse, with anorexia and other signs of gastro-intestinal 
disorder. When the result is fatal, there may or may not be recog- 
nized pathological alterations of the supra-renal capsules. 

Among the cutaneous disorders capable of producing skin pigmen- 
tation may be named scleroderma, lepra, angioma pigmentosum et 
atrophicum, eczema, especially e. venis varicosis, and general exfolia- 
tive dermatitis. 

From all of the discolorations named above, which are due solely 
to deposition in excess of coloring matters normally existing in the 
skin, it is necessary to distinguish the various dyschromia? which are 
owing to the introduction into the integument of coloring substances, 
either supplied by other portions of the body or entirely foreign to it. 
Thus, in icterus, the bile may color the skin from a light yellow to a 
dark chrome shade, the duration and severity of the cutaneous symp- 
toms depending upon the nature and gravity of the hepatic disease. 
It is frequently accompanied by pruritus in various grades of severity, 
the exact causes of which are obscure. 



Argyria. 

Here the bluish, bluish-gray, slate-colored, or bronzed colora- 
tion of the skin results from the introduction from without of the 
nitrate of silver. It is most commonly the result of the adminis- 
tration of the drug in the treatment of epilepsy, but is said also to 
have resulted from the topical application of the silver crayons to the 
throat, to the conjunctiva?, and even to the skin. Under what form 
the silver produces this effect, whether as an albuminate or other 
salt, is not known. The deposition, however, occurs in the form of 
minute particles of the metal in the connective tissue of the derma. 
The discolorations are most evident upon the parts of the skin ex- 
posed to the light, as the face and hands ; but the author has seen the 



CHLOASMA. 415 

chest and lower extremities similarly stained. The connective tissue 
of the viscera is also at times involved, showing thus that the action 
of light is not essential to the production of the dyschromia. Two 
cases are reported as relieved by the administration of the iodide of 
potassium. 

Chloasma from Ingestion of Arsenic. 

The administration of arsenic in full doses for relief of nervous 
disorders in children has been followed by a characteristic dull 
brownish or dirty-colored discoloration of the skin of the neck and 
chest. Several cases of this sort have been presented to the author's 
observation in his clinic, by Dr. H. N. Mover. 

Tattooing". 

By the process of tattooing, lastly, several mineral and vegetable 
substances are directly introduced into the corium by means of 
needles, for the production in the skin of various devices in colors. 
Individuals whose entire integument has been thus artificially covered 
with figures of different patterns by tattooing w T ith indigo, vermilion, 
and cinnabar have been from time to time exhibited in this country. 
The results are indelible. Post-mortem, these pigments have been 
discovered not only in the derma, but in the lymphatic ganglia 
nearest the site of their introduction. 

Pathology. — The lentigines, ephelides, and chloasmata are all due 
to excessive deposit of the natural pigment of the body in the rete 
mucosum of the epidermis. Restoration of the normal color of the 
skin is usually proportioned to the extent and depth of the deposit, 
but the process is always very gradual. It can well be studied in the 
slow bleaching of the pigmentation of syphilitic cicatrices upon the 
lower extremities. In the dyschromia? due to the introduction of 
coloring matters foreign to the body or foreign to the skin, the corium 
and subcutaneous connective tissue are commonly stained. 

Diagnosis. — The diagnosis of the cutaneous pigment hypertrophies 
is readily effected by observing the persistence of the discoloration 
under pressure ; the absence of all symptoms of hyperemia, inflam- 
mation, and secondary changes in the skin, as also by the charac- 
teristic shades of color presented to the eye. In tinea versicolor 
there is usually slight furfuraceous desquamation, and the existence 
of a vegetable parasite is readily demonstrated by the microscope. 
The rare pigmentary syphilide is usually seen upon the neck and 
shoulders of infected women in the form of yellowish to brownish 
maculations, often arranged in an irregular network. It is, indeed, 
one of the symptomatic chloasmata. 

Treatment — In all the symptomatic pigment anomalies, the indi- 
cations for treatment are presented by the disease which begets the 
cutaneous disorder. 



416 



DISEASES OF THE SKIN. 



The local treatment of both the idiopathic and symptomatic varie- 
ties of the disease demands the use of external applications which 
will hasten the physiological reproduction of the epidermis, substi- 
tuting thus new and unpigmented for old and pigmented epithelia. 
This must also be accomplished without the artificial production of 
such an hyperemia as will tend to add to the very coloration which 
it is attempted to relieve. The substances used for the slow accom- 
plishment of this end are borax, sulphur, tincture of iodine, potash, 
and soda (including the soaps of these alkalies), and the mercurials. 
None of these is more generally employed than corrosive sublimate, 
which constitutes the basis of most of the cosmetic lotions sold in 
the shops. 

The ibllowing are formulae given by Dr. "White 1 for use in the 
evening. The preparation in each case should be left upon the sur- 
face during the night, and removed by a soap and water washing in 
the morning. They are to be used for weeks in succession, but only 
after a cautious preliminary testing of the sensitiveness of the skin 
to their action. In order to avoid the possibility of error, the prac- 
titioner would do well to order a poison-label upon all vials con- 
taining the sublimate : 



R . Hydrarg. am. chlor. \ 



Bismuth, magister. 

Amyli 

Glycerin. 



R. Amnion, muriat. 
Aq. Colognien. 
Aq. 

R. Hydrarg bichlorid. 
Acid, mur dil. 
Glycerin. 
Alcoholis 
Aq. ros. 
Aq. 



aa gij; 



3ss; 



gr. vj ; 
aafgij; 



8 
16 

2 

32 

256 

4 
32 

64 

128 



M. 



M. 



M. 



The following are formulae for ointments given by Kaposi : 

R. Hydrarg. ammon. 
Sodsebiborat. 
01. rosmarin. 
Unguent, simpl. 



R. Acid, boracis \ 
Cerse alb. j 

Paraffin. 
01. amygd. dulc. 



Van Harlingen recommends : 

R . Hydrarg. chlor. corros. 
Zinci sulphatis \ 

Plumbi subacetat. / 
Aq. dest. 
Sig. Lotion, for external use, morning and evening. 



la ^ss; 


16 


gtts. x ; 

3j; 


32 


aa 3j ; 


4 


3y; 


8 
32 



M. 



M. 



gr. vss 

aa 3ss: 

fjiv: 



2 
128 



M. 



Loc. cit. 



KERATOSIS. 417 

Other preparations advised are : stimulation with alcohol, and 
application, for several hours after, of a plaster of aruinoniated mer- 
cury ; two parts of magnesium carbonate and zinc oxide, four of 
pure kaolin and glycerin, and ten of vaseline ; chloroform, one hun- 
dred parts, chrysarobin, fifteen parts (Leloir) ; peroxide of hydrogen ; 
diluted acetic, carbolic, muriatic, and nitric acids ; one to two parts 
of salicylic acid, in paste or powder, to twenty parts of base ; and 
solutions of mercuric bichloride in collodion, one part to thirty, em- 
ployed with great caution. 

The rapid removal of pigmented patches is accomplished, in 
Vienna, by covering the part with strips of linen dipped in an 
aqueous or alcoholic solution of corrosive sublimate of the strength 
of four grains (0.26) to the ounce (32.), with which also the dressing 
is occasionally moistened. Vesicnlation is usually accomplished in 
about four hours, when the serum is evacuated by puncture, and the 
detached epidermis covered with any inert dusting powder. The 
resulting crust falls in about eight days. The procedure is attended 
with danger of producing, in the end, the precise deformity which it 
seeks to remedy, a danger explained above. 

The internal administration of the iodide of potassium, recom- 
mended for the removal of argyria, has in my hands failed of any 
good results. YandelPs two patients, one completely and the other 
partially relieved, were both syphilitic. One of my patients was a 
veteran syphilitic, fifty years of age. 

Prognosis. — The prognosis is in all cases uncertain. There is 
strong reason to believe that the local treatment of all these dys- 
chromia? is, in the long run, ineffective. Those methods which ac- 
complish the desired end effectually and brilliantly are almost 
invariably followed by deeper pigmentation than that which it was 
attempted to remove. Those operating more slowly have, probably, 
a less speedy, but scarcely more disguised sequel. It is probable 
that local treatment of these pigmented states will ere long be aban- 
doned as inadvisable. The treatment intelligently directed to the 
cause of each discoloration is that which in the end proves most 
satisfactory. 



2. Of Epidermal and Papillary Layers. 
Keratosis. 

Gt., nipag, a horn. 

The term Keratosis was first applied by Lebert to hypertrophic 
lesions of the epidermis. It has since been made to include changes 
in both the epidermis and corium ; and is employed by some authors 
in a generic sense to embrace a number of both localized and general 
hypertrophies of these portions of the skin. 



418 DISEASES OF THE SKIN. 

[A.] Keratosis Pilaris. 
(Lichen Pilaris, Pityriasis Pilaris.) 

Keratosis Pilaris is a disorder, chiefly of the extremities, characterized by 
multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations 
of epithelium, about the orifices of the hair-follicles. 

Symptoms. — This condition may be a mere temporary and functional 
disturbance of the skin, awakening no subjective sensation, inappreci- 
able by the patient, and apparent only to the careful observer, or it may 
really constitute a disease. Its symptoms are the occurrence of pin- 
head sized, pointed elevations of the surface, which may be described as 
papules, though, strictly speaking, they are not such, constituted by 
an accumulation of horny epithelia and a small quantity of inspissated 
sebum about the lanugo hairs of the extensor surfaces of the extremi- 
ties and trunk. These aggregations of material are usually of a dirty 
whitish or grayish hue, and pierced by a lanugo hair implanted in 
the follicle about which the abnormal condition exists. Occasionally, 
however, the hairs are of the finer and shorter kind, and are often 
coiled in or otherwise covered by the little heaps of epithelial debris. 
The skin of the individual thus affected is generally harsh, squamous, 
and dry to the touch ; being also, in the majority of cases, long un- 
washed. The color of the quasi-papules also differs with the com- 
plexion of the individual ; at times they have a distinctly reddish 
tinge. They are often surmounted by a scale. 

The condition is sufficiently common in skins long uncleansed by 
ablution, and can thus be artifically produced. In some individuals 
it persists for long periods of time, and awakens no concern. In 
others, and especially in children, it speedily becomes the source of a 
pruritus, and each lichenoid papule may be then transformed into an 
urticarial wheal, with distinct and sometimes very annoying pricking 
and tingling sensations, the entire trouble being at once relieved by 
a bath in warm water with soap. In other cases, especially in adults, 
an exaggerated form of the disease can be recognized, the skin pre- 
senting a roughness to the touch suggestive of the nutmeg-grater, 
and exhibiting numerous fine, conical, grayish, horn-tipped filaments, 
which several dermatologists are disposed to regard as a form of 
ichthyosis. Here, there is doubtless a true hypertrophy of the 
epidermis. In the former case, there is scarcely more than a 
mechanical accumulation of effete organic material. There can be 
little doubt that the malady, simple though it be in character at the 
onset, may become the first stage of a series of chronic cutaneous 
disorders. Tilbury Fox has reported four cases in which the disease 
was well marked, under the title Cacotrophia Follictjlorum, the 
name being employed to designate its peculiarities as to wide distri- 
bution over the body, implication of the deeper portion of the follicles, 
and its congenital history. In these cases, the reddish tint of the 
lesions is distinctly shown. 



KERATOSIS. 4J9 

Brocq, who devotes an extensive chapter to this affection, describes 
four forms : (a) a white variety, the uncolored circumpilary papules 
being scattered over the arms, forearms, legs, and thighs, usually 
on the outer faces of the extremities ; (6) a mild form, in which some 
reddish papules are disseminated among those of the "white" class; 
(c) a form of medium intensity, where the papules are generally 
rosy-red in hue; (d) an intense form, where well-marked lesions 
occur over the surface of the chest, lumbar and pubic regions, and the 
folds of the larger articulations. 

Keratosis pilaris of the face, as described by French writers, is 
characterized by exceedingly minute, usually conical, occasionally 
obtuse papules pierced by a fine hair occurring over the brow, about 
the eyebrows, over the cheeks, and the infra-maxillary region. 

I have seldom been able to persuade myself, after a careful study 
of the best pronounced cases, that this keratosis is really a morbid 
state. Even when most numerous and vividly red, the lesions are 
wholly destitute of inflammatory symptoms, and the subjective sen- 
sations they induce are, as a rule, insignificant, the patients complain- 
ing at all in these matters being usually those exceedingly anxious to 
be rid of the disorder. The latter are readily divided into two classes : 
first, comely young women desiring to exhibit the bare arms in even- 
ing toilet; second, young men suffering from the delusion that they 
are victims of a u disease of the blood" or of syphilis. Viewed as a 
whole, the subjects of the best types of this so-called disease are men 
and women of exceeding vigor, with firm, well-developed muscles and 
shapely limbs. 

Pathology. — The disease is produced by the accumulation of the 
cells of the horny layer of the epidermis and sebaceous material 
about the orifices of the hair-follicles. In some cases the result is an 
irritation which produces a more or less persistent hyperemia of the 
periglandular tissue. 

Etiology. — Puberty and uncleanliness have been assigned as 
causes of the disorder; and both conditions may be in some patients 
effective. A careful study of a group of exaggerated cases, however, 
occurring in adult men and women, suggests more essential reasons 
for the disease. In such exceptional cases, the outer faces of the 
limbs and even the entire face of the belly may be covered with 
faintly pinkish or bright-reddish firm papules, many of them scale- 
capped, all seated at the orifice of a hair-follicle. In these patients 
there may be a history of regular ablution and persistence of the 
malady long after puberty. But in general they will be seen to have 
peculiarly thick, coarse, usually dark-colored skins, and also to be 
persons of marked muscular vigor and unusual development of most 
of the other bodily tissues. In brief, the disorder seems to be due 
often to marked inherited predisposition in persons of vigorous con- 
stitution. The varieties of keratosis pilaris seen in cachectic hospital 
patients, and in persons who have aggravated the disease by inducing 
a medicamentous rash upon the person, belong to a different category. 
Patients in the two last-named classes may be so perfectly relieved 



420 DISEASES OF THE SKIN. 

that there is no predisposition to return of the disorder, a relief not 
always to be secured by the others. 

Diagnosis. — The disease should be readily recognized by the 
peculiarities of its seat, its course, and the nature of its symptoms. 
From ichthyosis, it can be distinguished by its limitation to the 
orifice of the hair-follicle; from the transitory condition known as 
u goose flesh," by its persistence after the surface of the skin is thor- 
oughly warmed ; from papular eczema and the other lichenoid erup- 
tions, by the relatively insignificant character of the lesions, their 
evident association with follicular inertia, and the entire absence of 
inflammatory symptoms. 

The disease is to be carefully differentiated from pityriasis rubra 
pilaris. In the latter, the characteristic disorder of the scalp, the 
appearance of plaques of disease covered with fine pityriasic scales 
(often upon the tip of the nose and chin, exhibiting a peculiarly 
dark, smirched appearance), the affection of the nails, and the evi- 
dent admixture of the disease with some symptoms of seborrhoic 
type, suffice to determine its nature. 

It is a matter of very considerable importance to distinguish kerat- 
osis pilaris from the papular syphilodermata, since many male 
patients have for years swallowed medicaments for relief of a sup- 
posed syphilis whose sole symptom is a keratosis pilaris. But the 
papular syphilodermata are not persistent year after year, not per- 
sistently symmetrical, and not limited largely to the outer faces of 
the limbs, especially of the thighs. They are preceded by a history 
of infection and invariably accompanied by some other manifesta- 
tions of the disease. They are not limited to the orifices of the hair- 
follicles, and are not capped by the peculiar horny scaling tip of the 
papule of keratosis pilaris. 

Treatment. — For patients affected with this disorder in its typical 
forms it is not sufficient merely to order a bath. The bathing should 
be conducted systematically for years at a time. 

As soon as it can be well tolerated, the patient should be urged to 
bathe the entire surface of the body every morning, by the use of 
the sponge and cold fresh or salt water, following this with brisk 
friction by the aid of a coarse towel or flesh-brush. The daily and 
habitual use of this cold bath continued for years, in persons who 
can tolerate it (and patients affected with keratosis pilaris are usually 
of this class), accomplishes results of the most satisfactory character, 
exerting, as it does, a profound influence on the nutrition and health- 
fulness of the skin. 

For immediate treatment, however, of most of these cases the 
hot bath with soap is desirable. This may be repeated as often 
as required to remove the lesions, and followed, in the more urgent 
cases, by inunction with the fats or oils. In the congenital and 
severer cases, such as those described by Fox, cod-liver oil, inter- 
nally, should be ordered. 



KERATOSIS. 421 

[B.] Keratosis Senilis. 

The senile changes in the skin are commonly of the character 
studied by Xeuruann, in which granular opacities appear in rows in 
the corium, giving it a dull greenish-yellow or saffron-colored hue. 
Later, the fibrillar of the corium are almost entirely replaced by 
finely granular masses, the remaining fibres becoming swollen and 
gelatiniform, reverting thus to au embryonic type. 

Side by side w T ith these degenerative changes, but also without the 
latter, the skin of the aged may become harsh, dry, and unusually 
cornified either diffusely or in certain definite regions, such as the 
bauds, feet, or extremities. This may be regarded as the simplest 
form of keratosis senilis. The skin of the entire body, or of the 
region affected, is then dark in color, dry to the touch, occasionally 
covered with fine, rather adherent scales representing merely attached 
and cornified cells of the horny layer of the epidermis, and notably 
unprovided with the natural unguent of the skin. 

In a more advanced grade, the skin undergoes changes closely 
allied to epithelioma, w T hich often, indeed, both furnish the fii>t symp- 
toms of the latter and coexist with its gravest destructive effects. The 
skin, more commonly of the face, hands, or forearms, less often of the 
feet, legs, and genital regions of the aged, is covered with thin, horny, 
often greasy-looking, pin-head to nail-sized and larger, dark yellowish 
plates or scales, between which the integument w 7 hich has undergone 
the atrophic changes in the senile skin, is visible. Pigmented puncta 
and macula? may also appear, scattered irregularly over the surface, 
with rough, dirty yellowish to dark brownish, granular accumulations 
upon the skin of certain regions, such as the clefts beside the alae of the 
nose, the temples, etc. The appearance is quite suggestive, in some 
cases, of a seborrhcea sicca of the face. In many patients exhibiting 
these features a fully developed papillomatous, superficial, or deep 
epithelioma may be present. In other cases one or more varieties of 
the senile wart may be visible, as described in the chapter on Verruca. 

Viewing the subject of senile keratosis in the light of the knowl- 
edge had upon the subject to-day, it must be admitted that the 
boundary lines between it and epithelioma are not well established. 
Unquestionably the exaggerated lesions of the former disease are 
frequently the first stages of the latter, and the treatment of the skin 
of the aged, conducted on the general principles already set forth, 
should never lose sight of possibly serious consequences in one or 
more regions of the skin affected. 

[C] Keratosis Follicularis. 

(Psorospermosis ; Psorospermose folliculaire vegetante ; Ichthyosis 
follicularis; Acne sebace'e cornee.) 

In 1889 Messrs. Darier and Thibault, in France; White, in 
America ; and, later, Wickham, 1 Xeisser, and others, called attention 

1 Contribution a 1' Etude des Psorospermoses Cutanees, Paris, 1890. 



422 DISEASES OF THE SKIN. 

to a cutaneous disorder not previously distinguishable from all others. 
The eruption displayed was practically generalized in the few cases 
reported, and exhibited in greatest abundance over the limbs, the 
front of the chest, the inguinal and genital regions, the scalp, the 
face, and the loins. The first lesions were firm, pin-head sized 
papules, scarcely different in color from that of the surrounding in- 
tegument, which later assumed a deeper color, and, whether flattened 
or hemispherical, were soon covered with a grayish or brownish crust, 
greasy to the touch and apparently prolonged into depressions be- 
neath, much as the crust of seborrhoea sicca of the face is sunk 
within the orifices of the sebaceous follicles. The papules, as they 
increased in size and age, became darker in hue till eventually they 
were a deep brown and red, or even purple. A few exhibited scratch- 
marks and were covered with hemorrhagic crusts. 

Over the scalp the symptoms are practically those of a seborrhoea 
sicca, save that there is no tendency to loss of hairs. Over the face 
the parts chiefly involved are the temples, the inside of the concha 
of the ears, and the folds about the nares and lips. Here, as over 
the parts of the trunk named above, form dark, even blackish, strata 
of dirty and oily crusts, spontaneously shed. Beneath, as indicated 
above, there is usually a conical spur let into an infundibular depres- 
sion, the latter representing the patulous orifice of a pilo-sebaceous 
gland. Over the backs of the hand and fingers, the papules and 
crusts are less numerous ; but the former are closely set together and 
tend to coalesce. In the palms and soles are numerous almost im- 
perceptible lesions of the same type. As the disease advances to 
what has been described as a second stage, there is marked prolifera- 
tion at the sites of the follicles, with a minute pit in the centre of 
each, often surrounded by a reddish ring of varying shades of color, 
granulating, and filled centrally with either a puriform secretion or 
a comedo-like mass. The subjects of the disease often emit an offen- 
sive odor. 

The course of the malady is by progression with symmetrical de- 
velopment of the eruption in its sites of preference. The small 
number of patients thus far observed renders it difficult to ascribe 
exact limitations to the malady. I had the opportunity of examin- 
ing the patient exhibited by Darier before the Congress of Derma- 
tology and Syphilography, held in Paris in 1889 ; but have since seen 
the disorder in but one patient, a lad brought to my clinic in the 
following year. 

Etiology. — The disease has been held by Darier and a number of 
French and other Continental observers since 1889, to be due exclu- 
sively to the presence of oviform psorosperms or coecidise, parasites 
forming the second group of the u sporozoaires" of Balbiani — unicel- 
lular inhabitants discovered in epithelial cells of several of the ver- 
tebrates. Since the date, however, of these observations a number 
of competent observers have shown that the so-called psorosperms 
were really altered epithelial cells. 

In White's experience, a parent and child were each affected with 



KERATOSIS. 423 

the same keratosis, a clinical fact suggesting the possibility of inherit- 
ability. Darier and Wickham have attempted to show that psoro- 
spermosis is a generic term including, as respects a parasitic origin 
due to psorosperms, not merely keratosis follicularis, but also Paget's 
disease, and possibly molluscum "contagiosum," and certain of the 
superficial epitheliomata. 

Pathology. — Bo wen, Robinson, and others have found the disease 
to be due to a keratinization of the epithelial lining of the ducts of 
the pilo-sebaceous conduit, the projection outward of the corneous 
mass being due to the pressure of the new- formed horny material. 
The rete is separated below from the stratum granulosum ; and 
roundish bodies with a highly refracting membranous envelope inter- 
vene. These rounded bodies, as they are pushed forward, become 
much firmer, much less readily colored, and more distinct. It is 
these containing nuclei and nucleoli which were assumed to be 
encysted psorosperms. 

Diagnosis. — The disease is to be clearly differentiated from mol- 
luscum epitheliale, which is never so generalized, and always exhibits 
an enucleable mass containing the so-called molluscous bodies. The 
corneous forms of acne are eruptive elements which contain centrally 
a true corneous mass ; in keratosis follicularis there is a softish comedo- 
like central mass. The acne forms, further, are not generalized. In 
typical pityriasis rubra pilaris there can always be recognized over 
the dorsum of one or more phalanges, minute papules isolated and 
scale-capped which are manifestly pierced by a hairy filament, the 
best single diagnostic feature of the malady. 

Treatment. — So few cases have yet been observed that the treat- 
ment is still undetermined. The parts are to be well cleansed by 
shampooings, and then dusted with borated, salicylated, and absorb- 
ent powders. The French, acting upon the parasitic theory of the 
nature of the affection, employ parasiticides vigorously, salves con- 
taining pyrogallol or iodoform, and even cauterizations with the 
chloride of zinc. 

[D.] Keratodermia Palmaris et Plantaris. 

(Symmetrical Keratodermia of the Extremities ; Congenital 

Keratoma of the Palms and Soles [Unna] ; Ichthyosis 

Palmaris et Plantaris.) 

A symmetrical and well-marked thickening of the palmar and 
plantar epidermis occurs as a result of several effective causes to which 
special attention has been directed, in France by Besnier and Doyon ; 
in Germany by Unna ; and in this country by myself 1 in a communi- 
cation to the American Dermatological Association in the year 1887. 

Symptoms. — Four varieties, whose distinctions are tolerably clear, 
have been identified. 

In the first, there is symmetrical thickening of the palms and soles, 

1 Observations on Three Cases of Symmetrical Hand and Foot Disease, Med. News, Oct. 8, 1887. 



424 DISEASES OF THE SKIN. 

strictly congenital and accompanied or not by na3vi situated upon 
other regions of the body. The epidermis of the iuvolved areas is 
greatly thickened and a delicate erythematous halo extends beyond 
the border of the keratosis. The latter condition occasionally 
sweeps beyond the palmar and plantar regions to the dorsum of the 
affected fingers, toes, hands, or feet. The nails, teeth, and hair are 
not involved. 

The second group includes the more common variety of symmetri- 
cal keratodermia of the extremities developed during the second 
infancy, erythematous in type and possibly associated with a central 
neurosis. Here the epidermal thickening is exaggerated over the 
points of special pressure, though occurring independent of such agency, 
a fact well illustrated in my case where the thickening at times de- 
veloped while the patient was for mouths reclining in a hospital bed. 
The disorder is worse in winter. There is the usual hypersetnic 
zone at the border line of the keratosis, and great distinctness of defi- 
nition of the latter with perfectly sound skin between the islets of 
epidermis sclerosed at the points of pressure. There is usually a 
coincident hyperidrosis ; and a dislocation and structural change of the 
nails themselves. The keratinized sole or palm sheds its horny 
envelope either as a result of treatment or spontaneously ; and even 
in the most pronouuced cases, the disorder may yield completely. 

In a third form there are foci where the keratosis is declared in 
multiple isolated points over the palmar and plantar regions, always 
independently of pressure and contact — due to a central tropho- 
neurosis. In a sub- variety the orifices of the sweat pores are dis- 
tended by corneous plugs resembling comedones, with concentric 
lamellations. 

A fourth variety is a partial, entirely curable, and accidental kerato- 
dermia of the extremities, not to be confounded with the callosities 
described in another chapter. It occurs at any age under the influ- 
ence of pressures to which the limbs are unaccustomed. 

The diagnosis of all forms is to be made from eczema, chiefly by 
reason of the absence of well-marked inflammatory symptoms, of 
vesicles, and of eczematous patches in other regions of the body. 
Palmar and plantar syphilides are to be distinguished with great 
caution. The latter may be asymmetrical, especially if of " late " 
type ; exist where there is often a history of infection or other signs of 
lues ; and often ulcerate. They have also well-defined circinate 
borders ; and the lesions are more often multiple and isolated. 

The internal treatment is by the methods employed in psoriasiform 
affections. 

Brocq advises the internal administration of the arseniate of 
sodium in large doses. The local treatment is by prolonged macera- 
tion of the parts, followed by shampooings with green soap in sub- 
stance or tincture, followed by salicylated pastes, plasters, or solutions 
of the acid in collodion. Mercurial plasters and the mercuric oleates 
may also be used with advantage. Hydrate of potash in ten to 









KERATOSIS. 425 

twenty per cent, strength has been used as a lotion to stimulate the 
surface. Other formulae recommended are salicylic acid and calomel, 
each one part to twenty of the glycerol e of starch ; and one part 
each of resorcin, tartaric acid, and salicylic acid, to twenty or thirty 
of salve-basis. 

[E.] Angiokeratoma. 

Uuder this title, Mibelli {International Atlas of Rare Shin Diseases, 
1889, ii.) describes hempseed-sized, circumscribed, transparent tumors, 
rough, dark-red, corneous, and feeling like prickles, in the person of a 
girl fourteen years of age. Between these were scattered spots of the 
size of a grain of corn, the centre of each of which was darker than 
the periphery. This color completely disappeared under pressure. 
Spots of a similar kind, but fewer in number, existed over the toes. 
On section, cavernous blood spaces and epithelial hypertrophy were 
recognized. 

[F.] Keratosis Follicularis Contagiosa. 

H. G. Brooke describes by this term a rare and apparently con- 
tagious disorder occurring in children. Blackish macules developed 
symmetrically into deeply pigmented papules over the neck, shoul- 
ders, and arms. From these blackish specks protruded, which 
eventually resembled comedo-plugs and later protruded as spine-like 
filaments. The skin was, however, dry, never greasy, and the thorny 
excrescences were quite firmly attached to the tissue beneath. The 
disease was found to be essentially a hyperplasia of the epithelial 
cells, the first evidence of the operation of the external cause being 
apparent in the stratum granulosum, the chief result being declared 
in the common excretory duct of the pilo-sebaceous conduit. The 
disease was readily relieved by applications of lard saponified with 
caustic potash. 

[G.] Hyperkeratosis Striata et Follicularis. 

H. v. Hebra reports under this title the case of a young woman 
with isolated epidermic elevations, having a reddish margin, of both 
superciliary arches, over the bridge of the nose, the upper lip, the 
throat, shoulders, and arms. The lesions were flat or elevated, iso- 
lated or confluent nodules, constituted of heaped-up epidermis which 
could be removed without disturbing the papillary layer of the 
corium. Many were bean-sized, grayish-green elevations, conspicu- 
ous over the elbows, with underspreadiug epidermic cones buried in 
corresponding depressions beneath, which often bled freely when the 
cuticular mass was removed. Contrasting with these lesions, were 
striated elevations of epidermis extending either at an angle or along 
the longitudinal axis of the limb. The disorder was relieved by 
warm water and soap baths, followed by resorcin vapor and sali- 
cylated plaster. 



426 DISEASES OF THE SKIN. 

[H.] Parakeratosis Scutularis. 

This name has been given by Unna {International Atlas of Rare 
Skin Diseases, 1890, i.) to a rare condition occurring (first on the 
scalp) in a vigorous man where thick, somewhat greasy crusts en- 
veloped bundles of hairs, the separate filaments having yellowish 
and horny cuffs that were confused with the crust. Whitish scales 
and horny cylinders of perpendicular projection were visible over 
several portions of the face. Upon parts of the trunk were brown- 
ish spots, coin- to palm-sized, exhibiting horny cones which projected 
from the follicular orifices. The cones were covered with horizon- 
tally placed scales. Dark-reddish, moist, aud shining surfaces were 
exposed on their removal. Closely examined, the horny cones after 
such removal displayed several hairs which projected, one above 
another, from each cone, having been extruded from their follicles at 
different times. The author believes the disease to be allied to 
Devergie's pityriasis pilaris. 

Molluscum Epitheliale. 

Lat., molluscus, soft. 

(Molluscum Verrucosum, Molluscum Sebaceum, Molluscum 
Contagiosum, [Bazin's] Acne Varioliforme.) 

Statistical frequency in America: 0.139. 

Epithelial Mollusca are smooth, globoid or acuminate bodies, situated either 
within or upon the skin, and in the latter case either sessile or pedunculated, 
varying in color from a yellowish-white to a dark pink, and in size from that 
of a pin-head to that of a bean. 

Molluscum Epitheliale, a disease first recognized by Bateman, in 
1817, under the title Molluscum Contagiosum, is to be distin- 
guished from another, known for a long time as molluscum fibrosnm. 
The two disorders are quite distinct, and no longer to be confounded 
by a similarity in their names. 

Symptoms. — Typical epithelial mollusca are firm, roundish bodies, 
averaging in size the dimensions of a pea, and in color varying from 
a waxy whitish hue, nearly that of the integument, to the dark-red 
tint of all injected masses. They are either imbedded in the skin, 
or project from it in semi-globular tubercles, sessile or pedunculated. 
Usually a dark-colored aperture can be detected at the apex or side 
of the lesion from which, on pressure, milky and curd-like, semi- 
fluid contents cau be made to exude. Occasionally inspissated, or 
even horn-like masses, project from these orifices, as though forced 
out by a vis a tergo. The disease is rare, and the lesions usually 
single and isolated, though hundreds may appear upon the person of 
one individual. They consist of semi-fluid collections derived from 
that portion of the rete which either lines the sebaceous glands or 



MOLLUSCUM EPITHELIALE. 427 

penetrates between the papillae of the derma ; or are actual transfor- 
mations of the glands into cornified amorphous deposits, surrounded 
by thickened parietes. They may be artificially removed ; or be 
shed spontaneously ; or iuflame, suppurate, and result in circum- 
scribed abscesses ; or terminate by ulceration. Most often they are 
insidious and slow of development , and may persist for years with- 
out producing annoyance or subjective sensation. They occur on the 
face, the side of the neck, and the nucha ; on the penis and scrotum 
of men, and the breast and labia of women ; on the trunk ; on the 
flexor surfaces of the extremities, and the dorsal surfaces of the hands 
and feet. They are most common in children. In consequence of the 

Fig. 48. 




Molluscum epitheliale. (After Allen.) 

depression of the centre of the little tumors (which Hutchinson has aptly 
likened to small pearl buttons), they may suggest the lesions of variola, 
and were hence described by Bazin under the term, Varioliform Acne. 
That term is, however, by most writers employed to designate a 
totally different affection, a variety of acne vulgaris to which a 
chapter is devoted in this work. 

Hebra, Virchow, and Nicolaysen have reported colossal mollusca, 
as large as an orange or a small cocoanut. Microscopical examina- 
tion of these gigantic lesions demonstrated their identity with the 
smaller tumors. Similar smaller bodies have been found interspersed 
among epitheliomata. 



428 DISEASES OF THE SKIN. 

Etiology. — In England, where the disease was first recognized and 
where, according to Hutchinson, it is far more frequent than on the 
continent of Europe, the belief in its contagiousness is quite generally 
accepted. Excellent authorities are, however, divided upon this 
question. At present, the contagiousness of molluscum is not yet 
established. The belief in that doctrine is without question increas- 
ing. If contagious, the lesions must possess this power of trans- 
mission in an imperfect degree, one much inferior certainly to 
others recognized as contagious. Retzius, Vidal, Peterson, and 
Wiggles worth succeeded in producing the disease by inoculation of 
the contents of molluscous tumors. Allen, in an interesting com- 
munication upon the subject, 1 reports an abortive result from an 
inoculation practised in two places upon himself by Dr. Bulkley. 
He reports fifty cases observed among children in an infant asylum 
of New York City, and expresses himself strongly in favor of the 
contagious character of the disease. Experiments with inoculation 
have been, however, often unsuccessful. The proofs of contagion rest 
chiefly upon the circumstance of lesions observed simultaneously or 
successively on the breast of a mother and the mouth of her nursling, 
as observed by both Bateman and Allen, or upon the successive 
development of mollusca in several members of one family. Fox, 
of New York, has called attention to an interesting relation which 
would seem to subsist between mollusca and verruca, or ordinary warts. 
If simple warts are ever shown to be in a feeble degree contagious, 
it can scarcely be doubted that a demonstration of the contagiousness 
of mollusca will soon follow. Eczema, sweating (Turkish baths), 
pruritus, and maceration of the skin, predispose to their occurrence. 

There are not sufficient grounds for assuming that, in adults, they 
are associated with venereal disease. They are not rarely seen in 
large numbers upon the scrotum of youths who have never exercised 
the sexual function. 

Pathology. — Upon section, a typical molluscous tumor is found to 

contain either a thick caseous fluid, or a mass of smooth, whitish, 

and roundish bodies often clustered about a short stalk. Micro- 

FlG 49 scopically, these are seen to be composed 

of epidermal masses, fat globules, and 

peculiar bodies of oval shape, partly or 

wholly contained in an epithelial pod, 

the so-called " molluscous corpuscles." 

The origin and significance of these 

corpuscles have been the subject of a 

great deal of careful investigation with 

no little divergence of opinion as to the 

result. The disease has been consequently 

Molluscous corpuscles. regarded by many authors as one con- 

(After Kaposi.) eerning the sebaceous glands, and the 

fluid or more or less solid contents of the tumors as the result of the 

various metamorphoses which the pent-up secretion of those glands 

1 Journ. of Cutau. andVen. Dis., August, 1886. 




MOLLUSCUM EPITHELIALE. 



429 



underwent. By such authors, the disease is termed "molluscum 
sebaceum," "contagiosum," etc., and is classified with the sebaceous 
gland disorders. 

Fig. 50. 





The author's rare form of molluscum verrucosum. (From a painting in oil.) 

Attention is elsewhere directed to the fact (v. Keratosis follicularis) 
that by Darier, Wickham, and others, epithelial molluscum has been 
described as due to a parasite. The psorosperms supposed to be effec- 
tive in the production of a class of disorders called by these writers 



430 DISEASES OF THE SKIN. 

psorospermosis, are held to be the cause not merely of molluscum 
and keratosis follicularis, but also of Paget's disease of the nipple, 
and other epitheliomata. These positions have, however, been effectu- 
ally assailed by later investigators. 

The studies of Retzius, 1 Lukomsky, 2 Renaut, 3 Vidal,* and Thin 5 
make it clear that the disease is one which concerns chiefly the rete 
mucosum of the epidermis. The uame molluscum epitheliale, first 
suggested in this connection by Yirchow, in the title epithelioma 
molluscum, is hence seen to be appropriate in the designation of the 
disease. 

Molluscous tumors may take origin either in the portion of the 
mucous layer whose involution forms the lining membrane of the 
sebaceous gland, or in the prolongations of the rete downward between 
the papillae of the corium where there is no follicle. Jn either situa- 
tion, the molluscous elements are earliest recognized as simply en- 
larged epithelia which assume, as a consequence of this enlargement, 
a globular form. In the midst of these, there are certain individual 
elements which acquire a granular appearance, the granular masses 
finally giving place by union to a globoid or oval-shaped body, large, 
shining, and stratified or homogeneous. This is the molluscous cor- 
puscle which represents a colloid metamorphosis of the original epi- 
thelia. According to Ranvier, the stratum granulosum of the epi- 
dermis is composed of elements which contain minute particles of a 
substance called eleidin, the keratogenic material by whose transfor- 
mation the stratum corneum is actually produced. This substance 
Renaut declares to be abundantly deposited in the enlarging corneous 
globes characteristic of molluscum ; and the process is by him shown 
to be identical with that occurring in the transformation of the ele- 
ments of the mucous into those of the horny layer of the skiu. The 
pathological resemblance of certain molluscous bodies to epithelioma 
is thus very clearly suggested. 

According to Thin, 6 the internal root-sheath of the lanugo follicle 
is the original source of the disease, whence molluscous elements pass 
to inoculate, at various points about the follicular orifice, the adjacent 
epidermis. The coalescence of these points forms the tumor, in the 
course of the development of which the lanugo hair is shed, and the 
sebaceous gland disappears. 

Auspitz denies that the transformation of the prickle-cells of the 
epidermis into molluscous bodies has anything in common with col- 
loid or amyloid degeneration. Robinson classes the disease with the 
new growths. At present, we must be content with recognizing the 
molluscous corpuscle as the result of a transformation undergone by 
the prickle- cell. 

Diagnosis. — Mollusca resemble the lesions of variola more than 
any other cutaneous phenomena. They are, however, readily dis- 

1 Viertel. f. Derm, tmd Svph., 1877, iv., Heft 3. 2 Virchow's Archiv, Bd. lxv. 

3 Lyon Med., July 25. 1880. 4 Soc. de Biologie, 1877, 187S. 

5 Journ. of Anat. and Phys., vol. xvi., 1881 ; and Brit. Med. Journ., Jan. 15, 1881. 

6 Loc. cit. 



MOLLUSCUM EPITHELIALE. 431 

tinguished from the latter by their chronicity, their semi-fluid con- 
tents, the absence of febrile symptoms, aud the career of the vario- 
lous pustules. From warts they are also differentiated by their 
contents, hemispherical shape, and the dark punctum almost invari- 
ably present on one part or another of the lesion. 

Molluscum epitheliale in no way suggests molluscum fibrosum, 
with which it has only been confounded in consequence of the simi- 
larity in the two names. The tumors of molluscum fibrosum are 
solid new growths, usually occurring in great numbers upon the 
trunk of individuals in adult years. They may attain enormous 
dimensions, of several pounds' weight, and though in cases they de- 
generate by ulceration, they never have the curdy contents of mol- 
luscum sebaceum. 

Papillary warts are to be distinguished from mollusca, though 
without question lesions are to be occasionally seen of a type inter- 
mediate between the two forms. Warts are to be recognized by their 
general papilliform character, and their evident relation to the papil- 
lary layer of the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have dis- 
covered mollusca upon the genitals, and who suppose these lesions to 
be of venereal origin. An error in this respect can scarcely be com- 
mitted by the expert. Neither the solid papule of the initial lesion 
of syphilis when observed on the skin of the penis, nor the pustule 
and resulting ulcer of the chancroid, ever exhibit the particularly 
waxy look of genital mollusca with their depressed puncta. In such 
cases, the inguinal glands should always be carefully examined, re- 
membering, however, that a forcibly squeezed and cauterized mollus- 
cum may be accompanied by a sympathetic adenopathy. 

Treatment. — Molluscous tumors may be removed by a ligature, 
scissors, knife, curette, or the needle in contact with the negative pole 
of a galvanic battery, their contents having been previously expressed. 
When desired, the surface may be first chilled or frozen with the 
ether spray, to diminish the pain of the trifling operation. Bleeding 
is easily arrested by a pledget of lint. Occasionally the point of a 
crayon of nitrate of silver may be introduced, after their removal, 
either to check haemorrhage or to insure destruction of the cyst. 
According to Hebra, the return of the complaint, when it occurs at 
all, may be expected at points where no tumors have been removed. 

When the lesions are small and numerous, they may be made to 
exfoliate by the local application of green soap. Removal of the 
larger lesions may be followed by minute cicatrices. 

Prognosis. — The disease can always be terminated by removal of 
the tumors, the process to be repeated in case of recurrence. Cica- 
trices, when these result, are of trifling moment. 



432 DISEASES OF THE SKIN. 

Callositas. 

Lat., callus, hard flesh. 

(This condition is also termed Tylosis, and the callosity itself Tyloma 

or Keratoma.) 

A callosity is a whitish-gray, yellowish-gray, or brownish, semi-transparent, 
localized and circumscribed horny thickening of the epidermis of the skin, due 
to hypertrophy of the stratum corneum, most commonly occurring upon the 
hands and feet. Callositas is here employed to designate strictly acquired horny 
thickening of the epidermis. Under the title keratosis are described a series of 
congenital and other symmetrical thickenings of both palms and soles, tylotic 
and ichthyotic in type, often the result of morbid conditions in the nervous 
centres and entirely unconnected originally with pressure and contact effects. 

Callosities are superficial, circumscribed, dirty white, yellowish- 
white or darker, flattened, thickened, and horny patches of epidermis, 
dense in structure and usually insensitive. Section of a single plaque 
shows it to be largest at the centre and least at the periphery. They 
vary in size from a finger-nail to a section of a hen's egg, being at 
times larger ; and occur chiefly upon parts of the integument subjected 
to long-contiuued intermittent pressure, as the hands and feet ; also 
upon parts stretched over osseous prominences, as those over the 
ischia. They may be complicated by hyperemia, fissure, acute 
inflammation, or erysipelas ; and readily serve as foci of cutaneous 
disease (eczema, psoriasis, etc.). They are commonly encountered 
among mechanics, carpenters, shoemakers, etc. ; amoug persons wear- 
ing ill-fitting shoes (heel, ball, or big toes), stockings, or surgical ap- 
paratus ; among workers in metals, acids, or heated substances ; and 
among musicians (harpers, banjo- players, etc.). They are produced 
by such external causes as pressure, friction, chemical agents, and 
heat. By careful consideration, they can be readily distinguished 
from eczematous, psoriasic, and ichthyotic patches, being always 
limited to the sites of external contact. 

They are said to be so characteristic of the several professions and 
trades, that by their locality alone they point in many cases to the 
occupation of the individual who exhibits them. Often they are, in 
these cases, essential to the prosecution of such work ; and their 
removal would only expose a tender epidermis to the operation of an 
injurious pressure or friction. 

They are, pathologically, pure hypertrophies of the stratum cor- 
neum of the epidermis, the deeper layers of the latter as also the 
corium and subcutaneous tissue being quite unaffected. 

Callosities require treatment only when they are sources of pain 
or discomfort. They may be removed — surgically, by the knife; 
chemically, by the destructive action of acids or alkalies ; rationally, 
by disuse of the part to an extent sufficient to interfere with the 
operation of the cause. When painful, they may be poulticed. A 
nightly soaking of the part with warm oil, kept in contact with the 



CALLOSITAS. 433 

thickened epidermis during the hoars of sleep by a compress of 
flannel saturated with the same substance, will in the end always 
soften the induration. 

Callositas of the Hands, with Unusual Complications 
[reported by Dr. Morison, 1 of Baltimore], is illustrated by the case 
of a negro who was engaged in stoking the fires of a steamer. In 
this instance the combined effects of heat and friction resulted in 
ulcerations beneath the callosities which eventually produced necrosis 
and fall of some of the phalanges. This patient recovered as soon 
as the hands were properly protected, a fact which seems to justify 
the assignment of this and similar cases to a class apart from those 
which follow. 

Perforating Ulcer of the Foot [Malum Perforans Pedis ; 
Mai Perforant du Pied]. — This disorder, first named by Yesigne, has 
been studied by Messrs. Savory and Butlin, 2 Mr. Treves, 3 Duplay, 4 
Michaud, 5 and others. 

The name is an unfortunate one, since many cases to be classed 
only in this category have neither ulcerative nor perforating symp- 
toms. 

The first symptom is a proliferative thickening of the epidermis 
like a corn, usually single, occasionally multiple, appearing over a 
point of pressure (first or fifth metatarso-phalangeal joint, etc.). 
Inflammation and suppuration proceed beneath this thickening, 
spreading first to the soft parts of the sole and then to the bone itself. 
Gradually a sinus forms, reaching from the side of the corn to the 
deeper parts involved. Meantime the skin in the neighborhood 
becomes greatly thickened, heaping itself especially about the sinus. 
The ulcer which eventually forms is roundish, deep, and at times 
very destructive in its effects. 

Thus far, the lesion might be supposed to be the result merely of 
a greatly irritated corn, but other phenomena exhibited in these cases 
are quite inexplicable in this way. The nails are altered ; superfluous 
hair grows on the dorsal surface of the foot and the skin of the 
involved extremity ; pigmentation, erythema, or eczema may occur ; 
and the parts become affected with either anidrosis or hyperidrosis. 
These disorders have, again, been noted as the result of spinal injury, 
congelation, posterior spinal sclerosis, anaesthetic leprosy, and, in 
animals, after section of the sciatic nerve. Among the most common 
symptoms in typical cases are anaesthesia, neuralgic and rheumatic 
pains, hyperidrosis, and coldness of the feet. 

The author has had the opportunity of studying this disorder in a 
group of cases which illustrate both extremes of its symptoms. The 
perforating ulcer occurred in the following case : 

In the centre of a dense callosity which had formed over the right 

1 Journ. of Cutan. and Vener. Dis., Jan. 1886. - Med.-Chir. Trans., vol. lx., 1879. 

^ Lancet, Nov. 29, 1884. ■» Arch. gen. de Med., 1876. 

5 Lyon Med., 1876. 

28 



434 DISEASES OF THE SKIN. 

first metatarsophalangeal articulation of a young man, there was 
exposed the orifice of a siuus which could uot be made to close. 
The course of the disease was exceedingly indolent, the parts being 
the seat of little pain. The weeping from the sinus was scanty, and 
it was not surrounded by granulations. It was more an annoyance 
at first, than a serious disease. Finally, by the aid of a fine probe, 
it was discovered that the sinus beneath led to exposed bone. A 
deep incision was made at this point, and the osseous surface thor- 
oughly scraped, after which antiseptic dressings were applied. The 
sinus, however, reformed in time ; and it became finally necessary to 
amputate the toe and remove by the gouge a large portion of the 
head of the corresponding metatarsal bone. This operation proved 
successful in relieving the patient. 

The case next described represents a group in which typical symp- 
toms of the disease were marked without a tendency to ulceration. 
A servant maid, twenty-two years old, kept under observation in 
hospital for more than a year, had for several years previously, as 
also while under treatment, suffered from symmetrical recurrent 
tylosis of the soles of the two feet only, the hands being spared. A 
dense, thick, yellowish-gray cast of the entire sole of each foot was 
regularly shed every four months, leaving behind a soft, tender, and 
irregularly mammillated epidermis. Persistent maceration of the feet 
for weeks at a time, poulticing, absolute disuse of the organs for 
months, mopping with from ten to thirty per cent, solutions of caustic 
potash, applications of Hebra's diachylon salve, mercurial and tar 
ointments, were all futile in preventing the recurrence of the tylosis. 
After the cast of each foot was formed the use of the organs was 
almost iuterdicted in the act of walking, on account of the pain 
which was induced. 

The nail of each toe of both feet was roughened, scabrous, friable, 
and tilted up from the nail-bed so as to approach the vertical position. 
The hands were the seat of a persistent hyperidrosis, being constantly 
clammy and macerated witli the sweat that poured from them. The 
pulse was slow, ranging from fifty to sixty beats a minute. All 
other functions of the body were properly performed. 

In the group of cases to which reference is made above, there was 
always a symmetrical involvement of the entire sole or palm, either 
of both feet, or both hands and feet. The patients were young 
adults. The palms when involved never exhibited the translucent, 
yellowish, wash-leather-like appearance of the same condition of the 
soles, but rather suggested the dry, scaly features of the palms in 
certain forms of erythematous eczema of these parts, but always 
without itching, and always with coincident plantar tylosis. The 
soles, however, always presented the typical appearance of callositas 
throughout the entire region, the callosity reaching somewhat upward 
over the heel, and in certain patients relatively sparing the instep. In 
some cases the nails were not involved. The feet were always as 
cold to the touch as in pernio. 

Pathology. — The disease is, without question, a trophoneurosis. 



clavus. 435 

Histological examination has shown destruction of the myelin and 
axis cylinder of twigs of nerves supplying the affected parts. Ac- 
cording to Messrs. Savory and Butlin, the sensory and nutrient 
fibrils of the involved nerves degenerate in consequence of pressure 
exercised upon them by increase of the endoneurium, the motor 
fibrils escaping, owing to their large size and thicker medullary 
sheath, a view plainly untenable for all cases. 

Diagnosis. — The diagnosis is between tuberculosis and simple cal- 
lositas, a distinction readily established by the evident neurotic phe- 
nomena seen in the so-called perforating disease of the foot. 

Treatment. — Apart from the surgical interference called for by one 
class of cases, a roborant treatment, including the internal adminis- 
tration of iron and arsenic, has been followed by most favorable 
results. 

The Prognosis is doubtful. 

Clavus. 

Lat., clavus, a nail. 

(Corn. Fe., Cor ; (Eil de Perdrix ; Ger., Huhnerauge.) 

Clavus, or Corn, is a circumscribed callosity usually found upon the toes, due to 
epidermal hypertrophy, and provided with a conical spur of horny tissue be- 
neath, which is projected into a corresponding depression in the corium. 

Corns are hypertrophies of the horny layer of the epidermis, with 
the peculiarity of presenting inferiorly a coniform prolongation, 
which, being pressed from without inward upon the sensitive papillae 
of the corium, excites pain in various degrees. They vary in size 
from peas to large chestnuts, and are dense and callous when occur- 
ring upon those prominent parts of the foot where the boot, shoe, or 
gaiter, exercises its greatest pressure. When occurring upon the 
lateral face of a toe in apposition with another, the corn originates 
usually from pressure through the medium of the neighboring digits. 
It is then softer, from exposure to greater heat and moisture. Corns 
are often weather-sensitive, being unusually painful before, during, 
or after the occurrence of storms, and should therefore not be con- 
founded with gouty or rheumatic deposits below the skin. They 
are composed of superimposed, and often concentrically arranged, 
layers of epithelium, between which are occasionally found minute 
hemorrhagic extravasations. They are occasionally seen upon the 
palms of the hands. 

At the periphery of the corn the corium is unchanged, but at the 
point where its central cone is pressed into the deeper structures, the 
papillae are either atrophied or quite absent. 

Corns are rationally treated by disuse of the feet, or by the adjust- 
ment of properly fitted coverings for the same. They usually fall 
spontaneously after an attack of paraplegia and in the cases where the 
lower extremities are confined for a few weeks in surgical apparatus 



436 DISEASES OF THE SKIN. 

for relief of a fracture. They may be softened by prolonged macera- 
tion in water, poultices, or, best of all, oil, as in the treatment of 
callosities. Erasion and excision may be practiced, if demanded by 
an exigency. Where the sufferer must necessarily continue the use 
of the foot, the simplest and best treatment is as follows : The part 
is thoroughly macerated for half an hour, with water as hot as can 
be tolerated. Then the projecting callous portion of the corn is 
gently removed by cutting or scraping, till, as nearly as may be, the 
surface is level with the plane of the adjacent skin. The part is 
then dried, and the entire surface, both of the seat of the corn and 
the adjacent integument, is completely covered with many narrow, 
short, and nicely adjusted strips of rubber plaster. When the 
trifling operation and dressing are complete, the patient should bear 
firm pressure over the corn without flinching, and walk with perfect 
comfort. The plaster remains till it separates spontaneously, which 
is usually in the course of a few days. The corn is then macerated 
at night with an oil poultice, as described above, and the dressing 
afterward reapplied, usually the second time by the patient. Persist- 
ence in this course is followed by complete relief if the coverings of 
the feet be properly fitted. Caustics, employed by many, are usually 
unnecessary when there is no ulceration of the hard corn ; and are in 
this situation frequent sources of great distress. They are chiefly 
valuable in the treatment of the soft variety ; but should always be 
applied with a skilled hand. 

For this purpose, the crayon of nitrate of silver or acetic acid may 
be employed. The proprietary " corn salves " sold in the shops 
commonly contain the ointment of the nitrate of mercury, which 
also is a useful application to the soft variety of corn. The latter 
should be protected by the interposition of absorbent cotton or wool 
from contact with adjacent digits. 

As a rule, the ringed corn-plasters sold in the shops are inferior to 
the dressing with the rubber, or salicylated plaster, made to cover 
the entire corn. 



Cornu Cutaneum. 

Lat,, cornu, a horn. 

(Horn. Fr., Corne de la Peau ; Ger., Hauthorn.) 

Statistical frequency in America : 0.034. 

Cornua, or cutaneous horns, are circumscribed hypertrophies of the epidermis^ 
forming irregularly shaped, spur-like excrescences of different sizes. 

Cylindrical, conical, straight or twisted, angular and otherwise 
irregularly shaped and sized corneous eminences, single or multiple, 
are occasionally seen projecting from the scalp, forehead, nose, lips, 
ears, penis, or extremities. The sites of preference are in the follow- 
ing order, the scalp, forehead, temples, nose, lower extremities, male 



CORNU CUTANEUM 



437 



genitals and trunk. They are named from their resemblance to the 
similar appendages in horned cattle, but widely differ from the latter, 
which are always implanted upon osseous tissue. They are formed 
of dense and massed columus of epithelia, often resting upon some- 
what prolonged papillae. Occasionally, on section, they exhibit the 
concentric arrangement of the epithelia seen in corns, but, unlike the 
latter, have reentrant basal depressions into which the papilla? below 

Fig. 52. 




Varieties of cutaneous horns. 



penetrate. At times they are implanted in a dilated follicle, in which 
case the glandular elements participate in their formation. At times, 
also, they represent a corneous transformation of the epithelia which 
constitute warts. They are seen in all colors, but are often between 
a yellowish-brown and a brownish-black, with a fissured or wrinkled 
or longitudinally grooved exterior, like rough bark. They may be 
painless, or, like the other keratoses, become the seat of inflammation 
in various grades. They may be short or several inches in length. 



438 DISEASES OF THE SKIN. 

The largest specimen ever under the author's observation was seen 
by him in France, on the forehead of a man, where it had existed 
for fifteen years. It measured three inches in length. They may be 
shed spontaneously, never to return or shortly to reappear. They 
occasionally develop into epitheliomata, as has occurred once under 
the author's observation, in a gentleman over sixty years of age, 
whose epithelioma developed from a horn on the dorsum of the right 
hand, projecting about three-fourths of an inch. 

At the meeting of the American Association of Genito-Urinary 
Surgeons in 1887, Dr. Brinton, 1 of Philadelphia, exhibited an ante- 
riorly curved horn one and seven-eighths of an inch long and three- 
eighths of an inch in circumference, removed by him from the glans 
penis of an elderly patient, no member present having then seen a 
similar growth in that locality. Only fourteen cases were on record 
of a similar growth in this situation. 

In a horn growing from the lower lip of an elderly man exhibited 
at the author's clinic in 1886, the growth was longitudinally fur- 
rowed, and also at somewhat regular intervals transversely furrowed, 
presenting thus the appearance of the joints of the sugar-cane. 

The etiology is without question that of the senile wart for most 
cases ; though, as with epithelioma, horns occur in infancy. They 
have been recognized as starting from a sebaceous cyst. 

Pathologically, these hypertrophies are first developed either within 
a closed atheromatous cyst, or from remarkably elongated papilla? 
of the corium. They are made up of cornified and hypertrophied 
epidermal cells. 

Lebert shows that horns develop into epitheliomata in about twelve 
per cent, of cases. As horns are really metamorphoses of epidermal 
cells similar in many points to warts, it is not surprising that the 
two often undergo the change from benign to malignant epithelial 
growths. In a few cases horns have developed to an appreciable 
degree on epitheliomata. But under the microscope this horny meta- 
morphosis on a smaller scale may be recognized in a large number of 
epitheliomata situated on the back of the hands of elderly men who 
have been farm laborers, sewer builders, or workers in contact with 
the earth. 

Horns may be removed by extirpation, after which the surface 
upon which they were implanted should be carefully and completely 
cauterized. 

In formulating a prognosis, the possibility of an epitheliomatous 
result should not be forgotten. 

1 Journ. of Cutan. and Gen.-Urin. Dis., 1887, p. 272. 



VERRUCA. 439 

Verruca. 

Lat., verruca, an excrescence. 

(Warts. Fr,, Verrue ; Ger., Warze.) 

AYarts are pin-head to bean-sized and larger, soft or hard, circumscribed eleva- 
tions due to hypertrophy of both the epidermis and papillae of the skin. 

Warts are cutaneous excrescences ; sessile or pedunculated ; pointed 
or flat ; smooth, rugous, or having a cauliflower appearance ; pig- 
mented iu various shades, or of the natural color of the skin ; con- 
genital or developing after birth. They may be single or multiple, 
and occur upon the hands, feet, face, scalp, neck, genitals, and other 
parts of the body. They may develop slowly or rapidly, and persist 
for years, or disappear without apparent cause. They may be soft, 
dense, or even corneous to the touch. 

The several names given to the various forms of warts have 
chiefly a descriptive value. 

Verruca Acuminata (Condyloma ; Moist, Venereal Wart ; 
Ger., Spizen Warzen) is a filiform, papilliform, or cock's-comb-like 
vegetation. They are single or multiple ; at times hundreds coexist 
upon the genitalia and neighboring regions. In size they vary from 
a pin's point to a hen's egg, and may be larger. They are apt to be 
moist and secreting, being frequently covered with a puriform mucus 
of exceedingly nauseating odor. Upon the genitals, they are encoun- 
tered upon the glans, around the fraenum, and over the prepuce of 
men ; and in women, about the clitoris, labia, vagina, and anus. 
They are usually of a bright red color in these situations. When 
occurring upon the integument, they are firmer, drier, and exhibit a 
feebler tendency to luxuriant growth. In this form they may be 
recognized about the axillary regions, the umbilicus, the interdigital 
spaces of the feet, and even the face. Dr. Heitzmann once informed 
the author that he had seen them covering the side of the chin. 

The summit of these warts may be tufted, acuminate, or flattish ; 
on the surface of the skin, unconnected with mucous membrane, they 
may have the color of the unaltered integument. They are often 
minute and numerous as well as multiple and large ; or may be 
single throughout, though, as a rule, they multiply when untreated. 
The largest maximum development I have observed has been in the 
negro, in whose persons they may attain unusual proportions. There 
was lately exhibited at the author's clinic a male negro with a com- 
pound venereal wart of the penis, of the size of the largest orange. 

They are almost always the result of exposure of the sexual parts 
to venereal secretions (blennorrhagic, syphilitic, leucorrhceal, etc.), 
and, though observed in virgins, are decidedly rare in individuals of 
both sexes of that class. In pregnancy they often attain a large 
size and rapid development, but then, as a rule, disappear when par- 
turition is completed. 



440 DISEASES OF THE SKIN. 

There is doubt as to the fact of their contagiousness and of their 
furnishing an auto-inoculable secretion. Cocci and bacilli have been 
recognized in several varieties, thus explaining many otherwise ob- 
scure histories. 

Verruca Acquisita is a terra used to designate lesions devel- 
oped after birth. 

Verruca Congenita. — Congenital warts are usually first no- 
ticed in the course of several months after birth. They may be 
single or multiple, usually the latter, and are then arranged along the 
lines of distribution of the nervous trunks, the disposition of the 
lesions often suggesting the arrangement displayed in zoster of the 
trunk or other region. They are as a rule roundish, slightly pig- 
mented, scarcely larger than split peas. At times they acquire 
unusual dimensions. I have seen the neck and shoulders well cov- 
ered with lesions of this class in asymmetrical groups, the largest 
wart having the size of the section of an egg. 

Verruca Filiformis. — This variety of wart differs somewhat 
from the others, not only pathologically, as is noted below, but in its 
clinical features. They are pointed growths, slender, thread-like, 
often pedunculated, usually covered with a smooth and apparently 
unaltered epidermis, occurring upon the face, neck, eyelids, chest, 
and ears. Kaposi concludes that they represent minute fibromata. 1 

Verruca Glabra is distinguished by its smooth surface. 

Verruca Plana is the single or grouped, flattened or globoid, 
smooth or rugous formation like a plaque or button, usually pig- 
mented, and occurring upon the face, back, and hands. 

Verruca Senilis vel Plana (Keratosis pigmentosa). — These 
are bean- to coin-sized, smooth, and softish growths developed upon 
the face, trunk, and extremities of persons of advanced years. They 
are flat, usually pigmented, and have a granular aspect. They are 
readily separable by the finger-nail, and are then found to rest upon 
a reddish granular base. As the result of external injury (caustics, 
traumatism) they may become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the 
fingers and hands, as pin-head to pea-sized, usually discolored, papil- 
liform excrescences. 

Of the several varieties of warts it may be said, in general, that 
they are most frequently observed either on the hands or over the 
genital region ; that they are usually discrete but may be confluent 
and form palm-sized and larger elevated plaques ; that they may be 

1 See Dr. Taylor's observations as epitomized in the chapter on Fibroma. 



VERRUCA. 441 

soft, hard, smooth, rough, pointed, flat, brush-like, or like the comb 
of a cock ; that they may vary from a pinkish to a blackish hue ; 
that they may persist, occur in crops, or spontaneously disappear ; 
and may grow with great rapidity [Verruca Acuminata] to a large 
size and involve any portion of the body. 

Dr. Fox, of New York, has figured an interesting case in which 
warts occurred in lines tattooed on the skin of a young man. 

Etiology. — Most warts are nests of micro-organisms of different 
varieties. The precise cause of these lesions is, however, unknown ; 
but in early childhood, a period in which they are most frequently en- 
countered, it is reasonable to conclude that they result from external 
contacts. It is when the child begins to handle everything within reach 
that they usually first appear, and then about the hands. The acumi- 
nate or condylomatous warts chiefly occur in parts moistened with a 
blennorrhagic secretion, but unquestionably may originate from contact 
with leucorrhoeal or pathological, non-venereal discharges from the 
female genitals. The senile warts are more probably due to obscure 
changes in the nutrition of the integument. The exact etiological 
importance of the cocci and bacilli which many of them furnish, 
cannot be exactly determined at this time. 

Pathology. — Warts on section exhibit, microscopically, an hyper- 
trophy of the papillary layer of the corium concerned in their 
growth, with corresponding development of the vascular loops rising 
from the superior vascular plexus of the corium. Above these pa- 
pillse the rete is usually largely developed, the epithelia being mul- 
tiplied not only on the sides of the prolonged papillae, but immedi- 
ately over their apices. In all the dry varieties the stratum corneum 
is also hypertrophied, but this more especially over the summit of the 
excrescence. The filiform warts are composed chiefly of a slender fas- 
ciculus of connective tissue springing from the bundles below, enclosing 
a vascular loop and covered with an epidermis which is not apparently 
altered. Beneath all forms of warts there may be a substratum of scle- 
rosed connective tissue, constituting the firm base upon which they rest. 

Diagnosis. — It is a matter of importance to recognize the fact 
that many epitheliomas begin as warts ; and the verruca of those 
advanced in years should always be examined and treated with a 
view to this fact. In any suspicious case, the existence of one or 
more " perles " in the vicinity of a supposed wart should arouse 
suspicion ; as also a tendency, especially in the aged, for the lesion 
to break down into an ulcer. Warts on the face and backs of the 
hands of the aged are often of this class. 

Another class of warts are tuberculous in character, and, whether 
occurring in the young or the aged, are results of infection with 
tubercle bacilli, a generalized tuberculosis often originating in these 
lesions (v. Tuberculosis verrucosa). 

Great care must be had to distinguish the moist variety from 
syphilitic condylomata. In the latter there is usually a history of 
contagion with other syphilodermata upon the surface, such as 
mucous patches, palmar lesions, or papules of the face. Fibroma, 



442 



DISEASES OF THE SKIN. 



or molluscum fibrosum, generally occurs in tumors of greater num- 
ber, firmer consistence, and larger size. The tumor of molluscum 
epitbeliale greatly resembles a wart, but the waxy-whitish appear- 
ance of the lesion and its dark punctum at one point or another, 
sufficiently distinguish it. 



Fig. 53. 




Vertical section of the summit of a pointed wart. . a, papilla containing vascular loop ; 
c, stratum corneum ; d, hypertrophied rete. (After Kaposi.) 



Treatment — Warts may be removed by excision, erasion, or 
caustics (nitrate of silver, alkalies, acids, perchloride of iron, corro- 
sive sublimate, etc.). The larger growths upon the genitalia are 



VERRUCA. 443 

often highly vascular, and may demand the prior application of a 
ligature when they are pedunculated. Even the slender filiform 
warts will be found to contain a small vessel in the pedicle which 
requires cauterization after the excision. When the warts cannot be 
more readily removed by the knife or curved scissors, the Paquelin 
cautery may be used. The blackened eschar which is left prevents 
haemorrhage, serves as the best subsequent dressing, and is less apt 
to be followed by a return of the growth. In some cases, it is a 
useful expedient to transfix the lesion in several directions with the 
long needles used in gynecological practice, previously dipped in a 
fifty per cent, solution of chromic acid. 

One may also transfix the base of the wart a sufficient number of 
times with a needle connected with the negative pole of a galvanic 
battery, the positive being connected with the body of the patient by 
the aid of a moist sponge. 

The formula, according to which are made several of the proprie- 
tary "wart cures" sold in the shops, is as follows: 

Be . Acid, salicylic. 3 ss ; 2 

Cannabis Indie, extr. gr. v ; 33 

Collodion ifss; 16 M. 

Sig. To be painted over the wart with a camel's hair brush. 

For patches of warts, Van Harlingen recommends attacking one 
part at a time cautiously with the following paste: 

R . Pulv. acid, arseniosi gr. vj ; [40 

Unsrt. hydrarg. ") .- j .. J 

Emplart. hydFarg. / aa * S ' ad &* ; 8 | M. 

For warts not requiring operative removal, local treatment often 
answers well. Those about the genital region often disappear if 
persistently washed with a solution of tannin in alcohol, one drachm 
(4.) to three ounces (96.), after which they are dried and thoroughly 
dusted with boric acid or salicylic acid with lycopodium ; or burnt 
alum and rosin; or, what is most popular, dry calomel. Alum and 
lead lotions may also be substituted for the tannin and alcohol, and 
for a time kept over the parts as a compress. 

Prognosis. — Warts are benignant growths; and in childhood and 
early adult life need not suggest grave sequelae. It is far different 
in advanced years, for, though these excrescences possess even then 
no malignant character, they are the too frequent precursors of 
epithelioma. While it may be urged justly that the early lesions in 
such cases were really epitheliomatous and not verrucous, the fact 
remains that many warty formations of apparently benign character 
do in advanced years, especially when irritated by frequent caustic 
applications, undergo a cancerous metamorphosis. The tuberculous 
wart also may become the source of general tuberculous infection. 

Multiple Cutaneous Tumors accompanied by Intense 
Pruritus. — Under this title Dr. W. A. Hardaway, of St. Louis, 



444 DISEASES OF THE SKIN. 

described a rare disorder characterized by the occurrence of about 
sixty pea- to nut-sized, dense tubercles aud tumors covered by a 
thickened, scaly, and excoriated, often hemorrhagic skin. In some 
situations coalescence had occurred, forming thus long and narrow 
plaques of nearly the width and half the length of the finger of an 
adult. The lesions were seen upon the outer aspects of the arms 
and legs, the palms and soles, the sides of the fingers, and around 
the ankles, wrists, and elbows. The accompanying pruritus was 
intense and intolerable; and, having lasted for twenty-two years, 
was naturally associated with the degree of pigmentation often 
observed under similar conditions. The patient was an unmarried 
woman, fifty-one years of age, and declared that the lesions first 
appeared as "blisters." 

Specimens of these tumors, examined by Dr. Heitzmann micro- 
scopically, exhibited hyperplasia of the epithelial and connective 
tissues. The papillae were longitudinally elongated, branching, and 
provided with narrow capillaries. Numerous nests, greatly varying 
in size, and containing inflammatory elements with considerably 
enlarged bloodvessels, lay close beneath the papillary layer of the 
corium. These elements showed all stages of transition into basic 
substance. The deeper layers of the derma were built up of very 
coarse bundles of connective tissue and numerous elastic fibres. 

Synovial Lesions of the Skin. — Under this title should be 
described certain strictly cutaneous lesions which possess some impor- 
tance from a diagnostic point of view. I have had the opportunity 
of observing these in several individuals, where the exact nature of 
the disorder had not been understood. They occur in the form of 
wart-like projections from the skin, pseudo- vesicles, and bullae, 
always over the site of bursa? connected with tendons, traversing the 
small articulations of the hand and foot. They are seen over the 
metatarso-phalangeal articulations ; and in the hand most frequently 
over the dorsal face of the articulation between the distal and adja- 
cent phalanges of the index and thumb. The first form is that of a 
roundish, corneous, pea-sized wart with a yellowish centre, of long 
duration, usually insensitive unless roughly handled. When punc- 
tured, a syrupy, yellowish, or grumous fluid exudes, and continues 
to form after repeated puncture. Split-pea sized vesicles, and bullae 
as large as a silver fifty-cent piece, often exceedingly painful, are also 
seen, especially upon the feet, with simply an epidermic roof-wall. 
Each contains the same thickened, yellowish, or whitish fluid, occa- 
sionally mingled with masses like sago grains. In every case the 
contents of the lesion are supplied by a synovial bursa beneath the 
skin, with which the lesion is either directly connected, or in commu- 
nication by a short sinus. The treatment requires the complete ex- 
cision or destruction of the secreting cyst-wall. 

Mr. Sidney Jones, and Mr. Makins, of St. Thomas' Hospital, have 
exhibited several lesions of this character to the London Pathologi- 
cal Society. 



VERRUCA. 



445 



Papilloma. — This term has been loosely applied to a large 
number of cutaneous growths widely differing from each other, both 
histologically and clinically. It has been made to include the vege- 
tations of syphilis, the neoplasms of nsevus, and even the tubercles 
of lupus. 



Fig. 54. 




Papilloma, due to the ingestion of the iodine compounds. (From a painting in oil 
of one ot the author's patients.) 



The designation, papilloma, is properly limited here to such cir- 
cumscribed hypertrophies of portions of the skin as correspond with 
warts in their pathological significance. They may be defined as 
excrescences from the cutaneous surface, of a size considerably larger 
than any one of the varieties of the wart with the exception of the con- 
dyloma, usually presenting a luxuriant growth composed of elon- 
gated papilla?, bloodvessels, and enlarged rete, covered externally 
with a smooth epidermis like a pellicle, or, more commonly, branched 
and tufted with the cauliflower aspect, and then usually smeared with 
a puriform mucus. The tumor increases rapidly till it attains a 



446 DISEASES OF THE SKIN. 

maximum size, and then indolently persists. Lesions correspond- 
ing to this description, occur in carcinoma, syphilis, and lupus. They 
may develop upon any portion of the body. 

BeigePs Papilloma Area Elevatum is regarded by Crocker as an 
illustration of the results of the ingestion of one of the bromine salts, 
and this is corroborated well by the picture presented in one of my 
patients where the face was well covered with so-called papillomatous 
growths, as a result of the administration of the salts of iodine. 1 

Papilloma Neuroticum is a term which has been applied to ribbon- 
like verrucous growths classed by some authors with ichthyosis 
hystrix. They properly belong, however, to the category of verruca 
congenita. 

Nsevus Pigmentosus. 

Lat., ncevus, a mask. 

(Pigmentary Moles. Ger., Fleckenmal ; Fr., Tache Pigmentaire.) 

Statistical frequency in America : 0.064. 

Nsevus Pigmentosus is a congenital, circumscribed pigmentation of the skin, in 
single or multiple deposits, either with or without textural cutaneous change, 
or associated with the development of warts, plaques, tumors, or pilary hyper- 
trophy. 

Abnormal congenital pigmentations of the skin vary in color from a 
light yellow or chocolate-brown to a blackish hue, and may be single, 
or multiple and very numerous. They vary in size from a pin -head to 
tumors of considerable volume ; and are either ovoid or circular in 
contour, or so irregularly shaped as to present a fanciful resemblance to 
parts of the figures of the lower animals, whence the popular belief as to 
their origin in maternal impressions. They occur in both sexes; and 
upon the face, neck, trunk, thighs, buttocks, and external genitals. 
The term IST^vus Spiltjs is applied to those which occur in a smooth 
and otherwise unaltered skin ; N^evus Verrucosus, to those which 
are irregular and wart-like ; Njevus Pilosus, to those surmounted 
by a growth of shorter or longer, stiff or downy, dark-colored hairs; 
and Njevus Mollusciformis, or Lipomatodes, to the soft or firm, 
more or less elevated and projecting tumors. 

They may be, when multiple, symmetrically or asymmetrically 
developed upon the surface of the body ; and in either case may 
exhibit in their arrangement the controlling effect of the nervous 
system. In a case reported by myself 2 there were multiple mono- 
lateral pigmentary nsevi distributed over the left side of the trunk in 
the course of the intercostal nerves, and in such a manner as strongly 
to suggest to the eye their correspondence in site with the lesions 
of zoster of the same region. De Amicis 3 had previously reported 
a somewhat similar case. Four patients with precisely the same 
lesions have since been presented to my observation. 

1 "Dermatitis Tuberosa, due to the Ingestion of the Iodine Compounds." Read before the 
Amer. Derm. Assoc, 1888. The Medical News, Oct. 13, 1888 ; illustrated with a painting in oil. 

2 Chicago Med. Journ. and Exam., October, 1877. 3 Lo Sperimentale, March, 1876. 



N^VUS PIGMENTOSUM. 447 

The course of pigmentary usevi, after attaining their full evolution, 
is to persist unchanged for a lifetime. Their increase in persons of 
tender years is occasionally characterized by a relative rapidity. The 
author has seen a pilary nsevus upon the cheek of an infant extend 
over nearly double its original area in the course of two years. 

Lesions of this sort seem to occur with equal frequency in the 
two sexes. It is possible that they may be acquired after birth, as 
claimed by some authors, but it is much more probable that such 
presumably acquired cases are instances of rapid development from 
minute congenital pigmentary moles. 

A case of unusually large congenital nsevus lipomatodes associated 
with multiple pigmentary nsevi of several forms occurring in a child, 
was observed by the author in 1883, the report of the case made 
subsequently being illustrated by a chromo-lithograph. 1 The chromo- 
lithograph accompanying the original report of this case appears 
among the illustrations of this treatise. 

Pathology. — Anatomically, pigmentary moles are readily separable 
into two classes : first, those in which the pigment only of the skin 
undergoes hypertrophy (nsevus spilus) ; second, those in which both 
epidermis and corium are hypertrophied, forming verrucous, pilous, 
mollusciform, and other lesions. The distinction made by v. Baren- 
sprung, Gerhardt, and others, between these two classes and still a 
third, where the lesions are limited to the cutaneous regions supplied 
by one or several nerves (Xsevus Unius Lateris, Papilloma J^euro- 
pathicum) is more apparent than real : for a close study reveals a 
trophoneurotic influence exerted in all cases, even in the enormous 
tumors of a mollusciform type. According to Demieville, the pig- 
ment accumulation occurs iu the corium as well as in the epidermis, 
in the form of ribands stretching along the lines of the bloodvessels. 

Pigmentary moles very rarely disappear spontaneously. Their 
removal may be accomplished by excision, or by destruction with 
caustics or with the Paquelin knife, or with the needle by electrolysis. 
The last-named method is applicable only to the smaller and more 
superficial growths of this class. Fox 2 calls attention, in connection 
with this subject, to the need of passing the needle no deeper than 
the epidermis, sufficiently deep merely to "blister the surface of the 
black spot." 

Acanthosis Nigricans. 

Under this title both Pollitzer and Janovsky (Internal. Atlas of 
Hare Skin Diseases, iv., 1890, ii.), describe cases which at present it is 
difficult to recognize as instances of ichthyosis, of verruca, or of nsevus 
pigmentosus. In these patients the neck, mouth, parts of the trunk, 
genito-crural and anal regions, hands, axillse, and thighs, displayed 
grayish-brown and darker pigmented patches, covered in some places 

1 Journ. of Cutan. and Verier. Diseases, July, 1885. 

2 Electricity in Removal of Superfluous Hairs, etc., Detroit, 1SS6. 



448 DISEASES OF THE SKIN. 

by fine papillae, and in others with growths five millimetres in height. 
These are described in some parts as isolated papillomata, covered 
with spherical warts having a horny envelope. In parts there were 
ridges radiating from a central point. The mucous surfaces were 
also iuvolved. Over the hands of one patient the color was deeper 
aloug the lines of the veins ; and there was a glassy shimmer to the 
prominent normal areas of the cuticle. 

In sections made of the skin removed from one patient there was 
recognized dilatation of the bloodvessels and lymph-spaces in the 
papillary and sub-papillary layers ; increase of pigment cells ; enor- 
mous thickening of papillae and epidermis ; elongation and bifurca- 
tion of the rete-pegs, and some " suggestions " of epithelial pearls. 
A few colonies of bacilli having the shape of short, thick rods were 
discovered, but not in all of the sections examined. 



Xerosis. 

Gr., fypbg, dry. 

Xerosis is a congenital dryness and roughness of the epidermis accompanied by 
a moderate degree of furfuraceous exfoliation. 

Xerosis, also termed Xeroderma, is a term which has been 
applied to the disease sometimes knowu as xeroderma pigmentosum, 
or the melanosis lenticularis progressiva, of Pick. The term has also 
been employed to designate a simple asteatosis. It is also used by 
some authors as practically equivalent to ichthyosis. 

In these pages the term is used to describe a condition included by 
most authors under the title, ichthyosis. Such in many cases it really 
is ; but in others the appearance of the integument is really to be 
distinguished from that seen in the typical ichthyotic skin. The 
condition to which the name xerosis is here given is really one inter- 
mediate between keratosis pilaris and ichthyosis simplex. 

Symptoms. — The sole symptoms of xerosis are cutaneous. The 
skin of the body, in some regions more than others but at times uni- 
versally, is to the touch, dry, harsh, rough, and destitute of natural 
moisture and unguent. Closely inspected, the surface is seen to be 
scaly, the exfoliation being of the character described as furfuraceous. 
In some cases the hand passed briskly over the surface of such a 
skin will cause a moderate separation of a few of the scales in a 
scanty shower ; in yet others, while the surface seems quite fit for the 
furnishing of such free flakes of epidermis, one is surprised to note 
that the free flakes are more or less attached, and the clothing of 
the patient is not, as in some forms of psoriasic and pityriasic disease, 
covered with epidermal scales. In brief, there is not in progress a 
catarrh of the horny layer, as in some of the other disorders named ; 
but merely an unusual keratinic transformation of the elements of 
that layer. 

The parts chiefly involved are the extremities, more particularly 



ICHTHYOSIS. 449 

the hands, feet, forearms, and legs ; but all parts of the skin may be 
involved, including the face, temples, cheeks, and even the lips. 

The disorder is met with in all grades, from the mildest physio- 
logical dryness of the skin, almost suggestive of the so-called " goose- 
flesh," to that state in which the exhibition of the face only suggests 
an abnormal condition of the skin. The color of the latter in well- 
marked cases is always of a dirty yellowish or dirty brownish shade, 
suggesting the unwashed condition of the integument, and in extreme 
cases of older patients becomes rather deeply pigmented. It is seen 
in both sexes and at all ages, being a congenital condition whose first 
appearance is only clearly indicated after variable periods of time 
after birth. Red-haired individuals perhaps furnish the larger num- 
ber of well-marked cases. The general health is unaffected. Before 
puberty the affection, in northern latitudes, will often be inappre- 
ciable in summer, and distinct in winter. As maturity is reached, 
however, the condition becomes more or less permanent. 

This disorder is described by some authors as a variety of ichthyosis 
simplex, but the reasons for giving it a separate consideration are, 
that the disease does not furnish the typical plate-like scales of 
ichthyosis ; and, one child affected with what appears at first to be 
merely xerosis may exhibit a typical ichthyosis before puberty, 
while another will go through life, the xerosis of his childhood 
becoming simply the exaggerated xerosis of mature years, but never 
an ichthyosis. 

Xeroderma may therefore be regarded in one sense as a variety of 
ichthyosis, but cannot be described as a stage of the latter disease. 

The disorder is congenital, and readily distinguished from all fur- 
furaceous scaling diseases of the skin by the absence of inflammation. 
The treatment and prognosis are those of the disease next considered. 



Ichthyosis. 

Gr., ix&vQj a fish. 

(Fish-skin Disease, Xeroderma. Ger., Fischschuppenausschlag- ; 
Fr., Ichthyose ; Ital., Ittiosi.) 

Statistical frequency in America: 0.249. 

Ichthyosis is a congenital deformity of the skin, developed first in early infancy, 
and manifested in a general scaliness, in the formation of regularly outlined 
polygonal plates, or in the growth of larger masses of a corneous consistency. 

Symptoms. — This disorder is one which displays a wide variation 
in its symptoms. To the extremes in either direction two names are 
given, ichthyosis simplex and ichthyosis hystrix. 

Ichthyosis Simplex. — The earliest and mildest form of ichthy- 
osis simplex is, by many authors, held to be the condition of xerosis, 

29 



450 DISEASES OF THE SKIN. 

fully described in the preceding pages. It will be remembered, 
however, that such a xerosis may persist through life with the 
production at any time of the peculiar symptoms of the ichthyotic 
skin. In these earlier manifestations of the disease, then, the skin of 
the patient can merely be described as unusually harsh to the touch, 
moistureless, and covered with adherent or exfoliating, fine scales. 
The latter are not massed, imbricated, nor displayed in plaques, and 
are usually of a dull yellowish- white color. It is rare that the prac- 
titioner is consulted for the relief of this disorder; it is usually discov- 
ered when the skin is exposed for other purposes (exploration, vac- 
cination, etc). In a still more advanced degree, the scales are 
massed together, forming grayish and whitish, polyhedral elevations 
or plaques, regularly outlined and closely set together, especially 
upon the extremities and certain portions of the trunk. Elsewhere 
the scaliness described above may be present in a more marked 
degree. Variations occur, in consequence of which the plaques, 
bordered distinctly by the natural lines and furrows of the skin, are 
even depressed, centrally or completely, or assume darker shades of 
color than those described, brownish and greenish-brown. 

Ichthyosis Hystrix. — With and without the symptoms detailed 
above, the hypertrophy of the skin may, in circumscribed patches or 
larger areas, produce irregularly shaped, verrucous, corneous, corru- 
gated, wrinkled, or rugous masses, usually much darker in color than 
the patches seen in the simple variety of the disease, and more often 
also discovered in adult years. The resemblance is here rather to 
the rough bark of a tree than to the scales of a fish. In other still 
rarer cases, the excrescences assume a spinous, acuminate, or horn- 
shaped form. The hand passed over the surface perceives not only 
the excessive roughness, but also the dryness of the skin. Perspira- 
tion is imperceptible in the parts affected. The nails are friable 
and indurated; the scalp scaly, and covered with hairs of exceeding 
harshness. The palms and soles are often spared. Kaposi describes 
certain diffuse callosities occurring in the palmar and plantar regions 
differing from the ichthyotic patches elsewhere. The face is usually 
spared, but, when involved, only the slighter manifestations of the 
disease appear there, minute, superficial, scaly patches of a grayish 
tint. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these patients seems inapt for the eczematous 
and other complications of the less diffuse keratoses. The author 
has treated four ichthyotic patients for syphilis, and noticed in all a 
decided tendency to the production of lesions of the mucous surface 
without cutaneous efflorescence. The extensor are usually more 
implicated than the flexor surfaces of the extremities. 

Singular variations from the types described above are noted by 
observers. Hilbert, 1 for example, in a case of congenital circum- 

1 Virchow's Archiv, Bd. xcix., Sept. 3, 1884. 



ICHTHYOSIS. 451 

scribed ichthyosis in a young woman, discovered a growth of thick 
hairs, one centimeter long, over the left shoulder and arm. Weisse 1 
exhibited to the New York Dermatological Society a boy, ten years 
old, with haemorrhagic fissures iu au ichthyotic skin, double ectropion, 
corneous opacities, claw-like fingers, attachmeut of the ears to the 
sides of the head, and a generalized condition of the skiu, which 
became very red when warm, some doubt, however, existing as to 
the diagnosis. 

The most exaggerated types of ichthyosis are seen in the so-called 
"Porcupine," "Rhinosceros," or " Hedge-hog" patients. In these 
unfortunate beings the entire skin is converted into a rugged, brist- 
ling, warty, quilled, or horn-like envelope, suggesting the integument 
of* the animals named. Such conditions are represented by Mr. 
Henry Baker's case, described by Anderson. 

The terms, Ichthyosis Serpentina, Nacrea, and Nigricans, are em- 
ployed to designate those conditions respectively in which is recog- 
nized a snake-like appearance of the skin, silvery whiteness of the 
scales, or a dark pigmentation. 

Viewing the disorder as thus in various ways exhibited, it is seen 
to be a congenital deformity rather than a disease. It may be par- 
tial or general, though usually the latter, with intense manifestations 
over the extremities, especially over their extensor aspects, and 
relative immunity of the face, axilla? , groins, flexor aspects of the 
limbs, the palms and soles, the glans penis, and prepuce. 

Like xerosis, the deformity is rarely visible at birth, but usually 
becomes apparent before the completion of the first year of life. It 
is first manifested in the region of election named above — i. e., over 
the elbows and knees — and here also, as in xerosis, may be for some 
years only apparent in this latitude in winter, disappearing almost 
wholly in the summer season. In maturity, the deformity has been 
known to disappear also temporarily under the influence of inter- 
current disease (variola). One patient is said to have regularly cast 
a slough of his integument in the autumn. 

The general health is usually unimpaired. 

Ichthyosis Congenita. — This exceedingly rare deformity occurs 
as an intra-uteriue modification of the skin of the foetus, which is 
usually brought into the world as a non-viable monstrosity. The 
skin is represented by a thick, homy cuirass, deeply furrowed, and 
resembling plates of armor. The ears, lids, and lips are usually 
wanting, and replaced by corneous folds suggesting in appearance 
the corresponding features of a mummy. The fingers and toes 
resemble talons and claws. Death usually occurs in the course of a 
few days from both inability to secure nutrition by the act of suck- 
ing and from imperfect development of other organs than the skin. 

Ichthyosis Linguae ("psoriasis of the tongue") is a disorder de- 
scribed by the French under the title, leucoplasie. It is not a variety 
of ichthyosis. (Cf. Lichen Planus of the mucous membrane.) 

1 Journ. of Cutan. and Ven. Dis., 1883, p. 49. 



452 DISEASES OF THE SKIN. 

Etiology. — Ichthyosis is unquestionably a congenital disease, though 
its first manifestations are only apparent during the second year of 
life. It is said to be generally hereditary, but this statement should 
be accepted with some reserve for every individual case. One of my 
ichthyotic patients was married to his own cousin, and had by her 
five children entirely free from cutaneous disease. None of his 
parents or grandparents was similarly affected. The disease occurs 
equally in both sexes, and is liable to aggravation in cold climates 
and the season of winter. The general vigor and development of 
patients thus deformed are, as a rule, quite unimpaired. Kaposi 
says: "The cause appears to be a local anomaly of the nutrition of 
the skin, especially involving its epidermic and fatty elements;" but 
this scarcely meets the requirements of etiology. 

Thost 1 describes ichthyosis occurring in four generations. Ac- 
cording to the ascertained genealogy, the ancestor first known to 
have suffered from this affection had five male children who inherited 
it, while one girl and one boy were spared. One of these affected 
children had himself five children, of whom three males showed the 
anomaly, while one boy and one girl remained free. Another brother, 
of the second generation, had five male and three female children ; 
of these, four boys and two girls became affected. One of the latter 
(of the third generation) bore four children, of whom three girls 
inherited the disease, while the fourth, a boy, escaped. It appeared 
that the affection always showed itself within a few weeks after 
birth, in the form of a roughness of the palmar and plantar surfaces. 
With the growth of the patient the condition constantly increased 
in severity, the epidermis shedding in large shreds until the disease 
reached its maximum by the fourteenth year. There was a marked 
disposition to excessive sweating, particularly in the diseased locali- 
ties ; the sensibility of the skin remained normal. Microscopic ex- 
amination showed, in addition to the hypertrophied papillae, great de- 
velopment of the sweat glands, with marked thickening of the ducts. 
Treatment failed to give more than partial relief. 

In the Molucca Islands and some other isolated regions, ichthyosis, 
on account of its unusual prevalence, has been regarded as an endemic 
affection. But instances of this kind are readily explained, without 
referring to climatic influences, by the operation of the laws of 
heredity with intermarriages. 

Pathology. — The diseased, or, better, deformed, skin is found 
microscopically to be hypertrophied in various degrees according to 
the development of the malady, the proliferation of its elements 
occurring in connective tissue, papillae, stratum corneum, and blood- 
vessels. In well-marked cases of ichthyosis hystrix the elongated 
papillae are surmounted by dense cones of the horny layer of the 
epidermis, more or less concentrically disposed, with sclerosis of the 
connective tissue, and a relatively unchanged rete. In this last 
particular, the dense plaque of ichthyosis differs in texture from the 
wart. 

i Inaug. Diss., Heidelberg, 1880 ; Centralbl. f. Chir., 1881, No. 10. 



ICHTHYOSIS 



453 



The polygonal ichthyotic plates are composed for the most part of 
corneous epidermal cells, their long axes parallel with the surface of 
the skin, with an unusual accumulation of pigmeut granules between 
the strata. The interpapillary cones are enlarged ; the horny layer 
greatly thickened, the hair-follicles indurated, the papillae elongated 
but not branching, and their bloodvessels dilated. The sebaceous 
glands are frequently converted into cyst-like bodies, the coil-glands 
distended, and the panniculus adiposus diminished in size. 

Fig. 55. 



d- 




Ichthyosis hystrix, vertical section, a, masses developed from the stratum corneum ; b, cones 
formed by the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue 
of corium, exhibiting numerous vessels transversely divided. (After Kaposi.) 

Diagnosis. — Ichthyosis not only presents features which are so 
characteristic as to be unmistakable, but also those which can be well- 
nigh perfectly portrayed in plates. In this respect it differs from a 
long list of cutaneous maladies. 1 

Whenever necessary in the establishment of a diagnosis, aid of an 
important character can be gained in the history of the disease and 
in the entire absence of the lesions and lesion-sequelse, exhibited in 
the exudative and scaling affections heretofore considered. The most 



1 The admirable representation of the ichthyotic skin in plate F of Duhring's Atlas, is 
faithful in its exactness. 



454 DISEASES OF THE SKIN. 

conspicuous characteristic of ichthyosis, as distinguished from psori- 
asis, lichen ruber, and pityriasis, is the absence of inflammatory 
phenomena. 

Treatment. — The younger the patient applying for relief, the larger 
are the chances of improvement and possible recovery. Ichthyosis 
hystrix of mature years is practically incurable. Internal treatment is 
valueless. External treatment is directed to softening, macerating, or 
anointing the skin, and, as far as practicable, preserving it in a softer 
state. This is accomplished by frequent baths, alkaline, vaporous, 
or combined with the use of soap or green soap, and generally fol- 
lowed by an anointing with vaseline, dilute glycerin, or lard. The 
French, after the removal of the denser layers of the horny plates by 
the aid of soft soap and water, anoint the body by friction with the 
glycerolate of starch. Almond, cod-liver, neat's-foot, and linseed oils, 
or lanolin may be used after the bath. Only by the most assiduous 
perseverance is a desirable result obtained and permanently secured. 
In the severer hystrix varieties, the most annoying projections and 
rugosities may be removed by excision, the Paquelin knife, or, less 
preferably, by the aid of caustics. 

Subcutaneous injections of one-third of a grain (0.022) of pilo- 
carpine have been practised in ichthyosis, in order to induce sweating, 
with a view to the maceration of the skin. Van Harlingen recom- 
mends the following for use when the epidermis begins to shed after 
the external application of soft soap: 

R . Potass, iodid. 9j ; 1 33 

16 

M. 

Anderson recommends the wearing of pure vulcanized India-rubber 
garments, a method of treatment which the author has found too ex- 
hausting for all cases. 

Taking a general survey of the therapeutical management of ich- 
thyosis and its results, the course to be advised for the majority of 
patients is very clear. With but few exceptions, 1 the subjects of this 
deformity are either entirely relieved, or greatly better in hot weather 
and moist atmospheres. Under these circumstances, and having re- 
gard to the essential fact that the deformity is life-long in duration, 
patients should always, when practicable, select for permanent resi- 
dence a climate most conducive to the comfort of the skin. There is 
no step which the ichthyotic patient can take at all comparable in 
value with the important selectiou of a suitable environment. 

Prognosis. — Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with respect 
to a "cure" of the deformity. Treatment, persistent, prolonged, and 
properly directed in connection with suitable climatic influences, may 
do much to improve the condition of the skin. 

1 While these pages are in preparation, the author has been consulted by an intelligent 
patient who positively asserts that her ichthyosis is always aggravated by warm weather. 



Potass, iodid. 


Bj; 


01. pedis bubuli \ 
Adipis J 


aa ^ss; 


Glycerin. 


3j; 



ONYCHAUXIS. 455 

Onychauxis. 

Gr., owtj } a nail ; av^eu, to grow. 

Onychauxis, or Hypertrophy of the nails, is an abnormal development of these 
appendages of the skin hi any diameter. 

Symptoms. — This may be a congenital or acquired disorder. The 
nail substance may be developed to an unusual extent either as an 
idiopathic or symptomatic affection, and in each case may be simply 
increased in volume, extent, or number, or exhibit such increase in 
connection with secondary changes. Thus the nail may develop to 
an extraordinary length or breadth, preserving its general character 
as regards texture, color, and position ; or it may also be changed in 
any particular, becoming opaque, discolored, dirty yellowish, and 
blackish or brownish ; rugous, furrowed, horny, and rigid ; thick- 
ened in one part and thin, vitreous, and extremely fragile in an- 
other ; tilted to one side or another on its bed ; or projected backward 
in recurved, irregular lines. Finally, the matrix may be inflamed, 
suppurating, hemorrhagic, or the seat of an excruciating pain. 
One or more of the nails may be affected; in some cases the entire 
twenty are similarly involved. 

The diseases in which these changes occur as symptomatic lesions 
are numerous, since it is evident that the matrix, from which the 
nail is produced, would scarcely enjoy immunity in the case of pro- 
found alteration of the skin in its vicinage. Thus eczema, lepra, 
psoriasis, lichen ruber, syphilis, scarlatina, perforating disease of the 
foot, variola, and other diseases, are attended by changes of various 
grades of severity in both matrix and nail. 

The condition termed Paronychia (Whitlow), is that in which 
one or both lateral borders of the nail bury themselves deeply in the 
tissues adjacent, producing thus an exquisitely tender and painful 
state of the soft parts, which may suppurate or surround the attached 
limb of the nail with exuberant granulations. This is more frequently 
observed in the nails of the toes, as these appendages of the skin of 
the feet are liable to injury from the pressure of ill-fitting boots, 
gaiters, and shoes. In the condition described as Onychia, the 
matrix is not only inflamed, but the nail substance is, as a conse- 
quence, texturally changed. l$o strict line of demarcation, however, 
can be described between the two conditions. The term Onycho- 
gryphosis has been employed to describe the contorted deformities 
which cause it to resemble a claw. 

Onychomycosis is the name given to that condition in which the 
nail substance is invaded by vegetable parasites. In such cases, the 
nails become opaque, discolored, and thickened, with a noticeable 
friability at the projecting border. 

In Syphilitic Onychia, one or several of the nails may become 
affected, though it is quite characteristic of the disease to exhibit 



456 DISEASES OF THE SKIN. 

limitation to the extremity of a single digit. In such cases there is 
usually a very marked involvement of the peripheral soft parts, 
which may be infiltrated with gummatous material. The bullous 
syphiloderm, among the congenital manifestations of the disease, will 
at times form beneath or quite near the nail, and thus endanger its 
integrity. In both forms, ulcerative results are common, with secre- 
tion of a foul discharge. 

In the affection termed perforating disease of the foot, all the nails 
of the feet may exhibit a characteristic onychauxis. 

Traumatism (constant or intermittent pressure of shoes) may aug- 
ment the size of the nail in one or another diameter; and the de- 
formed talons resulting from gross and long-continued neglect (East 
Indian devotees, etc.) are illustrations of another type of hyperplasia. 
Supernumerary nails may be found on supernumerary fingers and 
toes; or double organs on a single digit ; or in unusual situations as 
over the scapula (Tulpius); or on a digital stump ; or in an ovarian 
cyst. _ 

With respect to onychauxis proper, two forms are recognized. In 
the first, the nail-cells are more closely set together and the resulting 
hypertrophy is declared, not in changes in bulk of the nail, but in a 
dense, thick, opaque, glossy, grayish-white transformation of the 
organ. It is perceptibly increased in weight and becomes so solid 
that it cannot be cut by ordinary implemeuts. It may be also, though 
not changed in bulk, altered in shape, its free border curved down- 
ward or upward. 

The second form represents a visible hypertrophy in bulk, the nail 
being enlarged in one or several diameters. Enlargement in a trans- 
verse diameter necessarily involves the soft parts adjoining. Vertical 
hypertrophy results in any one of the claw- or talon-like forms of 
onychogryphosis. 

Etiology. — Onychauxis may be congenital or acquired; idiopathic 
or symptomatic; and due to inflammatory changes in the corium or 
matrix of the nail ; to traumatism; to defective hygienic care of the 
general surface of the skin, including the nails ; and, perhaps, in ex- 
ceptional cases, to senile influences. 

Pathology. — According to Geber, there is in gryphotic nails a 
tolerably uniform cousistence superficially ; and in the deeper strata 
a harder or softer substance arranged in fan-like layers. In the 
former region, the nail is made up of small, roundish, or flattened 
cells containing variously sized dark granules. These have a linear 
arrangement along the longitudinal axis, and, in places, as along the 
higher transverse ridges, are more closely aggregated. More deeply 
the cells are irregularly grouped. According to Virchow, they con- 
tain, centrally, horizontal masses of horn, which descend laterally, 
including the so-called " medullary spaces." These are sharply 
defined loculi filled with a homogeneous, lustrous, yellow, or finely 
granular mass ; and in them may be found epidermal cells in process 
of keratinization. 

When the nail is lifted off, the bed looks short, arched, and 



ONYCHAUXIS. 457 

narrow. Beneath the epidermis accumulated upon the surface, the 
hypertrophied ridges, longitudinally arranged anteriorly, and the 
papillae more particularly, become visible, the latter containing large 
vascular loops surrounded by a small-celled infiltration. 

Treatment. — The treatment of the disorders of the nail described 
above, is largely that of the maladies in which they occur. Arsenic 
and iron are often indicated in these affections ; and their influence 
upon the nutrition of the nail cannot be questioned. In syphilitic 
onychia, the constitutional treatment of the disease is essential. The 
cutting, scraping, and trimming of the nail by the aid of the useful 
instruments found in the chiropodist's case, supplied by most surgical 
instrument makers, are important measures in many cases. 

The treatment of ingrowing toe-nail varies with the extent of the 
disease. In mild cases, soft threads of charpie are insinuated between 
the offending border of the nail and the tender granulating surface 
upon which it presses. Counter-pressure by plaster and the local use 
of the crayon of nitrate of silver, may be at times employed with 
advantage. In severer cases, the nail may be removed, though this 
is generally unwise. The soft parts are, by some surgeons, completely 
removed from the side of the nail by means of a thin-bladed bistoury ; 
and the nail permitted to grow down upon one side of the extremity 
of the distal phalanx, thus protecting the cicatrix and radically pre- 
venting the recurrence of the disease. 

The proper dressing of the feet in onychauxis of the toes is a 
matter of great importance. The shoes and socks, or stockings, 
should be adjusted both as to texture and shape to the special 
requirements of each case. After the hypertrophied tissue is largely 
removed by cutting or scraping, the phalanx may be enveloped in a 
plaster-mull or salve-muslin of diachylon ointment, or with mercurial 
plaster, and the whole covered with a leather or rubber cot. 

The Prognosis in these disorders of the nails rests eutirely upon 
the nature of the malady in which they occur. Idiopathic and 
localized changes, as also those occurring in transient cutaneous dis- 
eases (e. g., the exanthemata), often terminate favorably. In severe 
constitutional or grave cutaneous diseases, the outlook is less promis- 
ing. The diseases of the nail are usually more obstinate and less 
amenable to treatment than the similar affections of the softer parts. 
In cases where there is cougenital disease of the nails, a prognosis 
should be made with reserve. 



458 DISEASES OF THE SKIN. 

Hypertrichosis. 

Gr., vnep, in excess ; 6pl!j } hair. 

(Hypertrichosis, Hypertrophy of the Hair, Hairiness, Hirsuties, 

Hypertrichiasis, Polytrichia, Trichauxis. 

Fr., Poils accidentels.) 

Statistical frequency in America, 0.416. 

Hypertrichosis is a development of the pilary filaments, exaggerated as to size or 

number, or unusual either with respect to the location of the growth, or the 

age, or sex, of the individual in whom it is displayed. 

This anomaly may be congenital, and occur in various grades. It 
is sufficiently common to see infants at birth provided with extremely 
long hairs of the hairy parts of the body, such a growth being usually 
replaced later by shorter filaments. Universal congenital hirsuties is 
a rare deformity, the entire body being then covered with longer or 
shorter downy hairs of various colors. 

Fig. 56. 




The Russian " Dog- faced Man." 

Acquired hirsuties may be partial or universal, much more com- 
monly the latter. Thus the hairs of the scalp or beard may acquire 
an enormous vigor and length, reaching fully to the ground when the 
figure is in the erect position ; or the hypertrophy of the hairs may 
affect the face of the child or woman ; and in this sex, either the upper 
lip, chin, cheeks, or all portions of the body usually covered by hairs 
in man, be provided with a vigorously and symmetrically developed 
pilary growth. 

Remarkable instances of universal congenital hirsuties are occa- 
sionally observed. The so-called " Russian dog-faced man " (Andrian 
Jeftichjew) and his son, lately on exhibition in this country, were 



HYPERTRICHOSIS. 459 

noteworthy illustrations of this anomaly. In most cases the influence 
of heredity is usually distinct and often accompanied by defective 
dental development, such as entire absence of molar or canine teeth. 
In all cases of hypertrichosis, whether congenital or acquired, the 
parts normally unprovided with hair, such as the palms, soles, ungual 
phalanges, prepuce, glans penis, upper eyelids, and vermilion border 
of the lips, are not the seat of the pilosis. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so the hypertrichosis of women 
and children is at times related to a precocious, perverted, or arrested 
function of the generative organs. The reported instances of mem- 
struation in female infants and children usually include a description 
of abnormal pilary development about prematurely developed 
pudenda ; and after the climacteric period, when some women con- 
spicuously in external appearance begin to resemble individuals of 
the opposite sex, either isolated, thick, bristle-like hairs develop over 
the chin or lips ; or the extreme hirsute condition may be reached. 
Duhring 1 has reported one such case, which is illustrated by an excel- 
lent lithograph representing the face of a woman provided with a 
superb beard. 

The influence of the sexual organs in the hypertrichosis of women 
is well demonstrated in the following case coming under the author's 
observation. 

A married woman, thirty-three years of age, weighing one hundred 
and fifty pounds, mother of three healthy children, applied, in 1883, 
for relief of a general and facial hirsuties which had resulted in the 
growth of a full beard and moustache. She had not menstruated for 
more than a year, and had been pronounced by an expert to be past the 
climacteric. During the years 1884 and 1885, the author removed in 
successive operations the hairs of the face by the electrolytic method 
described below. Menstruation began while she was subject to the 
influence of the galvanic current in the operating-chair, and continued 
thereafter irregularly, at times with intense pain and even menor- 
rhagia. In 1886, after the last of the operations on the face, she 
rather suddenly lost in weight, decreasing to one hundred pounds, 
and began to menstruate regularly and painlessly. The hyper- 
trichosis of the general surface then disappeared by a simple fall of 
hair. In the latter part of the year she again conceived, and in 
March, 1887, being then quite free from any form of hirsuties, she 
brought a healthy male child into the world. 

As the result of the local application of stimulating and oily lini- 
ments persistently aud over a single region of the body (scapula, 
sacrum, sciatic notch, etc.), as also after traumatism by pressure or 
otherwise, a growth of long and numerous hairs is often produced. 
Care should be had in the management of cases of acne and rosacea 
in the persons of dark-skinned young women with luxuriant hair 
upon the head, lest this growth be precipitated upon the chin, cheeks, 
or nose. 

1 Arch, of Dermatology, April, 1877. 



460 DISEASES OF THE SKIN. 

In cases of hypertrichosis the hairs may be variously colored, and 
the hypertrophy of downy hairs be purely numerical, or result in 
increase in the actual size of the shaft of the individual filaments. 
In neither case do the hairs present auy anatomical peculiarities of 
structure. The localized congenital form of hirsuties is often charac- 
teristic of certain moles, known as Njevi Pilosi ; and the surface of 
pigmentary moles (NiEVi Pigmentosi) is often very extensively 
covered with hairs of a dark color. Singular anomalies have been 
figured by a number of dermatologists where extensive regions (one 
or several limbs, the entire back, even the greater part of the body) 
were the seat of enormous pigmented moles, covered with warts, 
fibromata, and other benign tumors, and clothed with a thick 
covering of longer or shorter hairs. 1 All such cases exhibit a striking 
development in either symmetrically or asymmetrically disposed areas 
of distribution of cutaneous nerves. 

The Hypertrichosis Neurotica, of authors, is that condition 
in which an excessive growth of hair has succeeded spinal paralysis 
and other morbid conditions of the nervous centres. Under the title 
Trophoneuroses of the Skin are described in this work changes of a 
similar kind, in which there is association of hypertrichosis with 
hyperidrosis, changes in the nails, and even extensive tylosis of the 
palms and soles. 

Under the name Plica Polonica was formerly described a con- 
dition supposed to be a disease peculiar to the Poles (whence its name), 
but which has long been recognized as a result merely of persistent 
neglect, filth, the invasion by parasites, and consequent exudative dis- 
orders, of the scalp. When it exists, the hairs form a huge matted 
mass on the crown of the head. Hebra has devoted some interesting 
pages to the superstitious awe with which this accumulation of hairs, 
lice, and filth has been regarded. In Alaska a number of cases of 
plica have been observed among the natives of that region. A typi- 
cal case of this curious deformity was lately presented at the author's 
clinic. 

Under the title Neuropathic Plica, Le Page 2 describes a case 
in which tangled "lumps" and "festoons" of hairs, flat, curled, 
looped, and intertwined appeared on one side of the head of a girl 
seventeen years old, who had previously suffered from neuralgic 
pains in the site of the growth. 

Etiology. — The causes of hypertrichosis are obscure. It is clear 
that whatever determines the blood in excess to any one region of 
the body may be indirectly the cause of hypertrophy of the hair, a 
fact demonstrated in the patients who, after applying sinapisms or 
liniments for years to the skin over the seat of a rebellious neural- 
gia, exhibit an abundant growth of hair, often several inches in 
length, over a scapula or a buttock. In women, whose sex renders 
the anomaly most deforming and distressing, it is chiefly noted, as 

1 See the author's case of naevus lipomatodes in a child, the pilary growth being at that age 
undeveloped. Journal of Cutan. and Ven. Diseases, July, 1885. 

2 British Medical Journal, January 26, 1884, p. 160. 



HYPERTRICHOSIS. 461 

has been observed, in precocious, perverted, or arrested activity of 
the sexual function. The neurotic conditions accompanying certain 
varieties of hirsuties may be inappreciable ; or evidently due to trau- 
matism ; or exhibited in paralyses, muscular atrophy, etc. It may be 
a racial peculiarity ; a family trait ; an inherited anomaly ; or an 
epiphenomenon in dwarfs, monsters, individuals affected with club- 
foot, insanity, and congenital deformities of several kinds. 

Treatment. — To Hardaway, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs 
by electrolysis, first devised by Michel, of his city. After him most 
American dermatologists have with success removed extensive pilary 
growths without subsequent reproduction of the hairs. A fine needle 
is introduced into the hair- follicle aud pushed well down to the 
papilla at its base. This instrument is connected with the negative 
pole of a galvanic battery containing six or more elements, the posi- 
tive pole of which is in connection with a sponge electrode held in 
the patient's hand ; the latter being thus enabled to make or break 
the circuit at will. When the current is passed, a few minute bub- 
bles of gas escape from the orifice of the follicle, and, when the hair- 
papilla is destroyed, the hair itself is readily extracted. The dex- 
terity acquired by practice is requisite for the proper performance of 
the operation, with a view particularly to the insertion of the needle 
at the proper angle into the follicle. Few patients complain of pain. 
The number of hairs removed at a sitting varies with the sensitive- 
ness of the patient's skin. The resulting scar is either quite imper- 
ceptible or far less disfiguring than the hirsuties, suggesting the 
appearance of the male beard after shaving. Transitory macula?, 
papules, pustules, and wheals, occur at the site of puncture. Care 
should be taken not to insert the needle too deeply in the particularly 
vascular regions of the face, as an aueurismal tumor might be pro- 
duced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as con- 
firmed by the author's experience, may be given as follows : 

1. As to the battery, any good galvanic battery may be employed. 
The author uses habitually a forty-cell stationary battery, whose 
switch-board is so arranged that any number of selected cells may 
be brought into the circuit. A galvanometer should be placed in 
the circuit indicating a current of from two to four milliamperes. 
The number of cells employed should be different for different indi- 
viduals, different parts of the face, and on different days with the 
same individual — e. g., a smaller number is required when a patient 
previously operated upon returns after a somewhat long period of 
rest. Tw r o to four cells only may be tolerated over the tip of the 
nose or upper lip near the septum nasi. Twelve to twenty may be 
well borne, after some experimenting, on an insensitive chin. 

2. The best needle is a carefully selected, exceedingly fine jeweller's 
broach, its shaft and point annealed by rapid passage through the 
flame of an alcohol lamp. It is often useful to have the point also 



462 DISEASES OF THE SKIN. 

well rounded on an emery-wheel. The irido-platinum needles are 
useful, but inferior for general work to the well annealed, carefully 
selected broach. 

3. The needle-holder should be simply a convenient insulated 
handle, sufficiently long to protect all the points of the operator's 
right hand from the current. The author employs Prof. White's 
long handle. Duhring's 1 is of the shape of a thin lead pencil or pen- 
holder, and is about four inches in length. The handle, or stem, is of 
hard rubber, through which passes a metallic rod, acting as a con- 
ductor for the transmission of the current. The needle is inserted 
into the needle-holder proper, which is slotted, the needle being 
clamped immovably by means of a screw-nut. On the other end of 
the stem there is an insulated inserting-pin attached to the cord lead- 
ing to the battery. The instrument is of proper weight, convenient 
to handle, and altogether well adapted for the operation. 

4. The patient should be seated or reclining at ease in a good 
light, with the handle of the electrode connected with the positive 
pole of the battery in one hand, ready to press the sponge into the 
palm of the other. In this way, at the bidding of the operator, the 
patient connects and breaks the circuit at will. The sponge attached 
to the holder should be wet with a solution of salt and water. 

5. As to further details of the operation it is well (a) to make the 
connection only after the needle is in situ ; (6) to introduce the latter 
with a gentle manipulation acquired only by skill — it is well char- 
acterized by Hard away as a " catheterization " of the hair-follicle — 
observing a certain degree of parallelism with the hair-shaft as the 
needle enters ; (c) to operate leisurely, making sure that the current 
is not broken by the separation of the hands of the patient, before 
the hair is completely free in the follicle. This last can be ascer- 
tained by gentle traction on the shaft in from ten to twenty seconds 
after the insertion of the needle ; (d) to operate in succession upon 
contiguous hairs when practicable, not selecting one here and one 
there, the latter course being productive of greater pain ; (e) never to 
use the positive pole in connection with the needle, an error which 
results in the production of unsightly pigmented blemishes on the 
surface of the skin. 

The previous employment of preparations of cocaine both hypo- 
dermatically and by inunction — e. g., the oleate of cocaine — in order 
to relieve or diminish the pain of the operation, may be followed by 
exceedingly unpleasant consequences. The author has seen a derma- 
titis, thus induced, persist for months. 

Dr. Prince, of Boston, 2 lays stress upon the accurate regulation of 
the current by the aid of the absolute galvanometer, which the author 
has found in his practice useful but not essential. Dr. Fox, 3 of New 
York, reports a gradual decrease in the number of hairs returning 

1 Amer. Journ. of the Med. Sci., July, 1881. 

2 The Exact Measurement of the Electric Current, and other Practical Points in the Destruc- 
tion of Hair by Electrolysis. 

3 The Use of Electricity in the Removal of Superfluous Hair, etc. Detroit, 1886. 



HYPERTRICHOSIS. 463 

after operation, proportioned to the improvement in the instruments 
and the skill of the operator. There can be no question that the 
percentage of such returns varies with these conditions. 

All patients affected with hirsuties are not to be advised the opera- 
tion. The author has declined to operate in many cases which were 
not deemed to belong to the class in which the best results of the 
operation may be expected. Young and vigorous women, usually 
unmarried, may point out hairs to be removed which are merely 
fully developed filaments of a thick downy growth, all of whose 
individuals are rapidly pushing to equal maturity. Here the opera- 
tion itself, by inducing hypersemia of the skiu, may simply hasten 
the hypertrichosis actually in progress, and thus aggravate the dis- 
order. In most cases when an operation is undertaken, both parties 
should fully understand the possible issue. It may also be a ques- 
tion whether it lies within the legitimate sphere of the physician to 
remove superfluous hairs from the habitually covered breasts and 
arms of women. 

This operation has unfortunately found its way into the hands of 
the unprincipled and the ignorant, who, in their efforts to extract 
money from the credulous, have in some of the larger cities brought 
the operation into poor repute. It is, however, all that can be 
desired if only it be performed by one with sufficient skill and strict 
conscientiousness, for if hairs are rapidly plucked away from their 
follicles while an electric current is merely passing, the return of 
each filament is prompt and mortifying to the patient. It should 
be, therefore, well understood to be a procedure requiring ample time 
on the part of the operator, and either remarkably good vision or 
eyes aided by a mounted lens. Not more than from forty to sixty 
hairs can be removed in an hour by an expert operator ; and there 
are few who can work with advantage more than one hour at a 
sitting, and more than two or at most three hours of a day. 

Hairy nsevi are best removed by complete excision. 

Depilatories for the removal of superfluous hairs operate by the 
destruction of the filament without obliteration of the papilla. The 
consequence is that the hairs are reproduced in the course of about a 
fortnight. Most of the compounds used for this purpose contain 
either the sulphate of calcium, sulphate of arsenic, or sulphide of 
barium, made into a species of paste with hot water. This is applied 
over the surface with a spatula, and permitted to remain till it dries, 
a period usually requiring ten minutes. It is then rapidly removed 
by scraping with the spatula, and the surface thoroughly cleansed 
with warm water, after which the skin is anointed with cold cream, 
or other similar unguent. 

Of these depilatories Duhring recommends the following : 



R . Barii sulphidi ^ij ; 8 

Pulv. oxid. zinc. ~l --_••• -,.-, 

Pulv.amyl. } aa 3 "J J ^ 



M. 



464 DISEASES OF THE SKIN. 

The following are formulae devised by French authors : 

& . Sodii sulphat. 3 iij ; 12 

Calcis \ . _ Ar . 

Aniylipulv. f aa 3 x i 4U M. 

To be finely triturated, and when used, to be made into a thin paste with 

water. (Boudet. ) 



R . Calcis 3 j ; 4 

Sodii carbon 3J s s; 6 

Cerat. adipis 3 j ; 32 

To be applied as a depilatory in the manner of a paste. 



M. 



All of these require caution in their use, and should never be 
intrusted to unprofessional hands. 

Shaving may be practised upon the hirsute face of women, and, 
with a similar end in view, epilation also ; the latter, particularly in 
cases of hypertrophy of the hair, limited in extent. Partial suc- 
cess has attended the thrusting into the follicles, of needles pre- 
viously dipped in various caustic solutions, or heated in various 
degrees, but these methods are all far inferior to electrolytic destruc- 
tion of the hair-papilla. 



3. Of Connective Tissue. 
(Edema Neonatorum. 

GEdema of the newborn is characterized by the occurrence of an 
indurated tumefaction of the skin, most noticeable in the lower ex- 
tremities of infants affected with impaired circulation. 

(Edema and sclerema of the newborn have long been confused. 
The distinction between them was first well established when Parrot, 
in 1877, under the title athrepsie, first described with clearness the 
morbid condition now recognized as oedema neonatorum. 

Symptoms. — The disease, which is of exceedingly rare occurrence 
in this country, is observed in infants prematurely brought into the 
world, or at term, and of feeble vitality. On the first to the third 
day after birth, the child is found to be drowsy and difficult to 
waken, with the posterior and other parts of the thighs and legs, the 
hands, and the genital organs pallid, cold, livid, and retaining the 
impress of the finger as do oedematous tissues in general. At this 
point recovery may ensue, but in severe cases the oedema spreads, 
always more marked in the lower portions of the body, as a result 
of gravity, the skin becoming violaceous red, deep yellowish, or 
dirty looking. As the disease advances the integument is more and 
more difficult of indentation. Meanwhile the little patient becomes 
more drowsy, its respirations fewer, its cry weaker, and its tempera- 
ture lower. Death may ensue from a pulmonary complication, from 
diarrhoea, or from any intercurrent disorder. Usually the child 
passes into a state of coma. 

When recovery ensues, the oedema becomes less marked, and the 



ACUTE CIRCUMSCRIBED (EDEMA OF THE SKIN. 465 

indurated skin more and more impressible. A few days, in satisfac- 
torily managed cases, suffice to restore the patient to a condition of 
health. In some instances the oedema begins in other portions of 
the body than those named ; and in others there is a marked febrile 
reaction. 

Etiology. — The recognized causes of the malady are prematurity 
of birth, exposure to severe cold soon after birth, poor hygiene, 
atelectasis of the lungs, and inability to take the nipple. 

Pathology. — Venous thrombosis, resulting in the effusion of serum 
into the subcutaneous tissue, is a consequence of the enfeebled action 
of the heart. The fat, on excision, is found to be particularly dense 
and yellowish. 

Diagnosis. — The distinction between oedema and sclerema neona- 
torum is not made without some difficulty, the disorders greatly 
resembling each other. In the latter, the joints and particularly the 
jaw are immobile ; the disease is apt to be generalized ; the firmness 
of the integument is greater ; and there is no tendency to an oedema 
chiefly marked in dependent parts of the body, for example over the 
lower limbs. The color of the skin in the two disorders may be 
nearly the same. The pitting on pressure of the swollen skin is 
highly characteristic of oedema neonatorum. Scleroderma does not 
occur in children before the close of the first year. 

The Prognosis is grave ; but recovery may occur with assiduous 
attention when the oedema is not generalized. 

The Treatment is that of sclerema neonatorum. 



Acute Circumscribed (Edema of the Skin. 

(Angioneurotic (Edema.) 

This disorder has been described chiefly by Quincke, Riehl, 1 Mil- 
ton, Strtibings, Eapin, and a few other observers. 2 It is character- 
ized by the occurrence in successive and recurrent attacks, very rarely 
persistent in character, of circumscribed, oedematous, infiltrated and 
non-pruritic plaques, developing with acute symptoms and as rapidly 
disappearing. The surface of the affected area is commonly red- 
dened in various shades, from a light rosy hue to a vivid red. The 
plaques vary in size from a small coin to the section of a large orange, 
and may even considerably surpass these dimensions. The cellular 
tissue of the skin and mucous membranes is chiefly involved ; but the 
papillary portion of the corium is also largely concerned in the mor- 
bid process, as is also the superior vascular plexus of the pars papil- 
laris. Though as a rule no itching is awakened, the elevated disk 
may be the seat of a sensation of considerable burning or tension. 

Though each individual outbreak may be rapid of occurrence, the 
disorder which is responsible for the cutaueous symptoms is uuques- 

1 Wien. med. Presse, 1888. No. 11. 

2 Cf. Courtois-Suffit (Annal. de Derm, et do Syph., 1889, p. 859). 

30 



466 DISEASES OF THE SKIN. 

tionably chronic in duration ; and it is the successive and repeated 
expression of its influence upon the skin, which in rare cases pro- 
duces a more or less persistent and obstinate cutaneous oedema limited 
to one portion only of the integument. 

The Iesioos occur upon the conjunctiva, pharynx, larynx (where 
severe obstructive consequences may result), and also as facial symp- 
toms, especially upon the lids and lips. The lesions are to be recog- 
nized also upon the penis, scrotum, and vulva. The persistent oedema 
described later and attributed to recurrent attacks of erysipelas and 
lymphangitis is not of this class. 

Diagnosis. — The disorder should not be confused with ery- 
thema multiforme, erythema nodosum, giant urticaria, syphilitic 
and rheumatic nodes, nor with pseudo-lipomas. Between some of 
these affections, especially the three first named, no precise limits can 
be drawn, and the diagnosis must be made largely from the concomi- 
tant symptoms and from the absence, in circumscribed oedema, of 
itching or pricking sensations, febrile complications, and rheumatoid 
pains. 

Treatment. — Circumscribed oedema is produced under the influence 
of the trophic and vasomotor nerves ; it is hence amenable chiefly 
to those remedial agents which tend to favorably influence the 
nervous centres. Internally : ergot, iron, nux vomica, quinine, and 
the sodic salicylates are indicated. Diuretics, sudorifics, and cathar- 
tics are recommended by Besnier and Doyon. The local treatment 
is largely that of urticaria. I have generally ordered with advan- 
tage in these cases, salt and water over the region of the spine, ap- 
plied by the hands of a competent nurse. The salt is moistened 
with cold or slightly warmed water, according to the constitution and 
temperament of the patient, and is then briskly rubbed with a firm 
hand over the entire spinal region. The back is then sponged for 
several minutes with pure water, at first hot and gradually cooled 
till the surface is well reddened ; when lastly the surface is dried and 
the patient made to take moderate exercise. The result in many 
cases is brilliantly satisfactory. It is not to be forgotten that in 
many of these patients, especially women, mental anxiety and dis- 
tress, as in chronic urticaria, are responsible for a great part of the 
trouble. 

Circumscribed and persistent cedema of a single member or 
region of the body, not of the class of successive and repeated swell- 
ings noted above, is properly considered with the early stages of ele- 
phantiasis. It results most often from a localized lymphangitis or so- 
called recurrent erysipelas (chronic eczema of the face, tumefaction 
of nose and cheeks, due to obstruction by tumors of the antrum of 
Highmore), and appears upon the face usually as a smooth, shining, 
whitish or reddish, tumefaction, ill-defined as a rule, in a few cases 
with fairly good definition. The swelling is usually of firm con- 
sistence, but can with some pressure be indented with the finger. It 
is said to be always the seat of passive hyperemia, never of active 



SCLEREMA NEONATORUM. 467 

inflammation ; but this statement should be accepted with some re- 
serve, as in the case of smokers of tobacco and hard drinkers an 
active inflammation is sometimes awakened. These patches are 
rarely painful or tender ; one is usually consulted with a view to the 
relief chiefly of the consequent moderate deformity. They occur as 
well upon the lower limbs and breasts of women. 

The Treatment of these cases is by frequent shampooiugs and em- 
brocations, to stimulate the absorbents, aided by elastic compression. 
Facial deformities of this class are always benefited by abstention 
from the use of tobacco and alcoholic stimulants, the diet being at 
the same time carefully regulated. The nasal cavity, the region of 
the orbit, and the mouth (caries of the teeth, etc.), should always be 
questioned with a view to the removal of the cause. 



Sclerema Neonatorum. 

Gi\, GK?i7jp6g } hard ; veov, lately ; yevvdu, to bring forth. 

(Scleroderma Neonatorum. Fr., Sclereme des Nouveau-nes.) 

Sclerema Neonatorum is a disease recognized at birth or in early infancy, and 
characterized by coldness and induration of the skin and immobility of the 
body. 

This disease is not to be confused with oedema neonatorum, from 
which it is wholly distiuct in character. 

Symptoms. — At birth, or between the second and tenth days after, 
the lower limbs of the child assume a livid or whitish-yellow ap- 
pearance, occasionally suggesting the hue of wax; and become of a 
leathery consistency. This condition spreads gradually over the lum- 
bar region, the dorsum of the body, and the chest in front and behind, 
and, in the course of a few days, may involve the entire integument. 
When pressed upon with the finger, the skin produces the impression 
of half- frozen tissue ; the face suggests a cold and rigid mask ; the 
thighs in their sockets and the arms in the shoulder-joints are immo- 
bile. Usually there is somewhat less firmness of the abdominal in- 
tegument. The taking of the nipple, deglutition, and even the 
opening of the oral labial orifice, are effected only with great difficulty, 
and eventually become impossible. The respirations are shallow 
and imperceptible ; the pulse, in well-marked cases, imperceptible at 
the wrist ; and the thermometer in the rectum is not raised to the low- 
est register of the ordinary clinical instrument. There is often no cry. 

There may be a coincident icterus ; and often sprue has been ob- 
served in the mouth before the declaration of well-marked symptoms. 
The congenital patients are often stillborn. The most of all sub- 
jects of the disease perish before the ninth day. 

Etiology. — The immediate cause of the malady is retardation of the 
circulation in the cutaneous capillaries, and this may depend upon 
prior disease (pleuro-pneumonia, intestinal disorders) or to condi- 
tions operating before or at birth (congenital syphilis, feeble vitality). 



468 DISEASES OF THE SKIN. 

Pathology. — BallantyDe has observed a small-cell growth in the 
corium, of perivascular situation; Langer ascribes the condition to 
excess of fatty acids in infants as compared with adults, with the 
result of producing a fat consolidation. In Northrop's cases (Arch, 
of Pcudiat., vol. vii, 1890) no fluid escaped on section of the tissues, 
which were as semi-solid as if frozen; scattered haemorrhages in- 
volved the alveoli, connective tissue, and lymph spaces of the lungs, 
but there was no collapse. According to Ballantyne, the disease is 
due to overgrowth of connective tissue leading to atrophy of the fat 
cells and dependent upon a trophoneurosis. Parrot, himself, recog- 
nized the fact that the connective tissue trabecular were more numer- 
ous and thicker than in other cases. 

The Treatment of both oedema and sclerema neonatorum is by ele- 
vating the bodily temperature (in an incubator, wrapping the entire 
body in wool, warm-water baths, etc.) and by improving the nutri- 
tion in every possible way (sterilized milk and stimulants by the 
stomach pump, through nose, or pharynx). The body may also be 
well rubbed with warmed oil or camphorated alcohol. Brocq suggests 
frictions with the warm hand from below upward. 

Scleroderma. 

Gr., OKlrjpog, hard ; Sep/ua } the skin. 

(Hide-bound Skin, Dermatosclerosis, Chorionitis, Scleriasis, 
Sclerema Adultorum. Ger., Hautsclerem ; Fr., Sclerodermic) 

Statistical frequency in America, 0.030. 

Scleroderma is a chronic affection, characterized by a circumscribed or relatively 
diffuse induration, rigidity, fixation, and subsequent atrophy of the skin, the 
affected parts being yellowish-white, waxy, or pigmented in color, and either 
elevated or depressed, the morbid process enduring for a series of years, and, in 
certain cases, terminating fatally after the induction of marasmus. 

[A.] Diffuse Symmetrical Scleroderma. 

The skin symptoms of the disease may be preceded by prodromic 
pains of a rheumatismal character or by singular cutaneous sensa- 
tions (pricking, tingling, formication), or by muscular cramps, and 
neurotic sensations. In some instances also, there are vesicles, blebs, 
scales, local hyperidroses, or losses of sensibility in the skin which 
is about to become the seat of the eruption. 

With and without these prodromic features, the skin, chiefly of 
the upper portion of the body, becomes symmetrically involved in 
an obscurely defined oedema of a firm character, involving the sub- 
cutaneous tissue, and at first pitting under strong pressure with the 
finger, but later becoming as indurated and tense as hard leather. The 
integument is usually exceedingly difficult to pick up between the 
finger and thumb, and is shining, smooth, waxy, or of alabaster-like 
hue ; in other cases it is of a dirty, yellowish, grayish shade. This is the 
stage of infiltration, and when pronounced, is not to be mistaken for 



SCLERODERMA. 469 

any other condition. The face is then, both to the eye and the finger 
mask-like, immobile in features, and expressionless. The lips are opened 
with difficulty; the lids, though similarly stiffened, are much more rarely 
involved ; the back of the neck is firm ; the chest, shoulders, and arms 
either immobile or movable with difficulty; the ribs are bound down 
so firmly by the cuirass of leathery integument that respiration may 
be seriously impeded. The temperature is not changed, and the 
sweat may or may not be exuded over the affected areas. The ab- 
dominal surface is relatively spared. This condition may come on 
very insiduously, and require months or years for its full evolution ; 
at other times the progress is rapid, and the evolution even subacute 
in type. 

Often the upper extremities are so involved that the fingers re- 
semble carved talons ; the wrists lose their flexibility ; the forearms 
their usefulness. So extreme is the helplessness of some patients that 
they require both to be dressed, w T ashed, and fed, even when able to 
travel with relative comfort : 

The lesions are accompanied at times by other cutaneous disorders, 
such as subcutaneous tubercles, eczema, erysipelas, canities, anidrosis, 
zoster, and acne. 

In the later, or atrophic stage of the affection, the most pronounced 
of the symptoms are, like the cedematous or infiltrative stage preceding, 
symmetrical and more extensively declared on the upper segment of 
the body ; but the contractured part is generally less in area than that 
of the tumid integument. The skin becomes then more and more 
tightly stretched and thinned over the underlying structures ; and it 
is no longer possible, as before, to draw the finger over the surface, 
leaving a yellowish-white tracing of its route, w r hich disappears as 
the circulation slowly returns along the line. When this is extreme 
the skin becomes dry, scaling, fissured, or even ulcerated ; the mus- 
cles may considerably waste, thus reducing a limb several inches in 
circumference ; the teeth may fall ; the fingers be permanently flexed 
into the palm, or the forearm on the arm. When the condition 
becomes to this extent grave, the patient who before seemed to enjoy 
a fair degree of health, suddenly exhibits signs of constitutional im- 
pairment ; rheumatoid pains, neuralgias, and intercurrent visceral 
disorders gradually bring on a marasmus which in some of the re- 
ported cases has ended fatally with renal, cardiac, or pulmonary 
symptoms. 

[B.] Circumscribed Scleroderma. 

Gr., floppy, by metathesis, form. 

(Morphcea, Keloid [of Addison].) 

Circumscribed Scleroderma, or Morphcea, is characterized by the 
occurrence of one or several discrete, well-defined, firm, and smooth 
points, patches, lines, or bands, often slightly elevated or depressed, 
and surrounded by a delicate violaceous or lilac-tinted halo, whose 
involution may be followed by macular, punctate, or striate atrophy 
of the skin. 



470 DISEASES OF THE SKIN. 

This form of scleroderma was once held to be rare. It is, how- 
ever, more commonly under the observation of the expert than is 
usually believed. French authors distinguish between the variety 
displayed in plaques and that occurriug in bauds. Some forms of 
the latter are better described as linese atrophica?. 

Symptoms. — The patches of morphoea commouly begin as rosy or 
violaceous maculae which irregularly extend in area from nail- 
sized to larger patches, either with relative rapidity or slowness. In 
a variable period of time the centre of each patch becomes whitish, 
while the peripheric portions of the plaque retain their peculiar shade 
of color. There is thus formed a roundish or oval or irregularly 
outlined area, rarely larger than a dinner-plate, with a somewhat 
elevated infiltrated " lardaceous " central portion, or flattish and near 
the level of the adjacent skin. The blanched centre has often the hue 
of old ivory ; later, this may be irregularly commingled with a flattened 
streak or band, to be distinguished with difficulty from scar tissue. 
These patches may be single or multiple ; in the latter event arranged, 
as a rule, along the line of distribution of the cutaneous nerves 
of the trunk, along the inner face of the thigh, more often on the 
lower than over the upper extremities, and asymmetrical in the most 
of cases. When the tissue is pinched between the thumb and finger, 
it at first produces the impression of stiffness and hardness ; in the 
later stages of the disease the skin may be so atrophied over the 
region involved that it is impossible to make this test. The surface 
is dry and smooth, or, when very carefully inspected, seen to be 
traversed by exceedingly delicate lines. In other instances the 
plaque is dotted pretty regularly with depressed points resembling 
the patulous orifices of sebaceous glands of the face in certain cases of 
acne, the slightly discolored minute, funnel-shaped orifices contrast- 
ing thus with the dead-white hue of the patch. In other cases this 
appearance of dotting or picking out of the surface, is more conspicu- 
ous at one part than another, being, for example, well shown at an 
advancing border, with a dead-white, depressed centre, or at both 
extremities of a long oval. 

The border of typical patches is highly characteristic. It is made 
up usually of a narrow zone having a pinkish, lilac-tinted, or 
violaceous hue, which, when closely viewed, is seen to be constituted 
of a fine plexus of vessels. This zone may be wholly wanting, as 
is well shown in one of the author's cases where the temple was in- 
volved ; it may further be present in such degree as to be fully as 
conspicuous as the whitish central area. In a patient presenting a 
palm-sized patch over the sacrum, together with a few multiple spots 
on the side of the neck (a portrait of the same having been made in 
oil), the flame-like, violet-shaded areola extended for several inches 
on one side away from the disk, and one of the larger vessels of 
which it was constituted was distinguishable at a distance of several 
feet from the patient. Purplish, and even blackish, hues have been 
at times recognized in the halo by other observers. 

As a rule, there are few subjective phenomena ; in some cases 



o 



C3 






SCLERODERMA. 471 

itching, tingling, pricking, and other sensations are experienced. The 
variations observed in this affection are as numerous as they are 
striking. The disease may be extensive or limited to one or a few 
very small spots. The names, maculosa, nigra, lardacea, alba, plana, 
atrophica, etc., are merely descriptive of clinical features, and are 
rapidly becoming obsolete. 

Between the several types of scleroderma noted above, are to be 
found instances which it is difficult to assign to the one class or 
the other. Some are mixed forms in which diffuse scleroderma is 
developed in one part of the body and a circumscribed form in an- 
other ; in other cases morphoea plaques have developed to generalized 
symmetrical scleroderma. As a rule, the symmetrical forms are 
developed most extensively over the upper part of the body ; while 
the more frequent unilateral plaques of morphoea occur in greater 
proportion upon the lower limbs. Often the symptoms of the disease 
resemble at the outset those described in oedema neonatorum with 
pitting of an oedematous surface under pressure. The greatest varia- 
tion has been noted as regards the presence, absence, or exaggeration 
of sensibility. Sweat and sebum may be secreted or not from the 
affected patches. 

In the generalized forms, whether symmetrical or not, there may 
occur serious complications from visceral disease, cardiac, vascular, 
and renal complications, due in part to the interference with the 
normal function of large areas of the skin. In some cases the 
mucous surfaces are involved. In others there is strong reason to 
believe that there are organic changes in the viscera, as well as sym- 
pathetic disturbance of function. Some of the visceral muscles have 
been recognized as involved in scleroderma. 

Occasionally the patches are symmetrical. According to Besnier 
and Doyon, pigmentation is one of the important among the coin- 
plexus of sclerodermatous symptoms. Apart from the pigmented 
dots visible over the sclerosed patches, there often exists over the 
regions not as yet affected, a species of chloasma in the form of 
bronzing, diffuse or in irregular islets, over the neck, shoulders, and 
elsewhere. These pigmentations are often interspersed with the 
whitish patches of vitiligo. 

The course of circumscribed scleroderma is either chronic, lasting 
for from one to ten years or more ; or subacute, with evolution ac- 
complished in a few days and an almost rapid involution ; or atrophy 
may slowly or rapidly follow, with extreme tension, resulting even 
in the production of attachments to periosteum, or in severe cases in 
muscular atrophy and deformity due to the resulting contracture. In 
a few instances ulceration has ensued. In yet other cases absorp- 
tion of the material constituting the plaque is effected without sequelae 
of any sort, few, if any, traces of the process remaining. 

The band form of circumscribed scleroderma usually occurs in 
ribbon-shaped elongations stretching along a limb in its longitudinal 
axis, or over one-half of the face. Most of these cases are distin- 
guished by the occurrence of either an elevated ridge or a furrow, or 



472 DISEASES OF THE SKIN. 

(what is not very rare) an elevated ridge with a furrow on one side 
The median line of the forehead is the commoner site of this anomaly 
on the face ; over the trunk it is best displayed on the breast. As 
noted above, some of the cases collated in this category are instances 
of linese atrophica?. 

Finlayson 1 has observed in one case symmetrical gangrene of the 
extremities, a complication related without doubt to the " symmetrical 
asphyxia of the extremities " described by a number of English 
authors. The so-called " Glossy Fingers" and the " Sclerodactylie " 
of symmetrical distribution, may belong to the same category. 

The exaggerated forms of the disease noted by several authors, 
where, to a varying extent, the surface of the lateral half of the face 
has been involved, have been described as Hemiatkophia Facialis. 
Here not only the subcutaneous tissue, but the aponeuroses, perios- 
teum, and bones may participate in the atrophy, a fact well illustrated 
in the case of Robinson's patient, 2 whom the author had the oppor- 
tunity of examining. In this instance there was also a distinct 
sclerodermatous lesion on the face of one thigh. 

Etiology. — About three-fourths of all cases occur in women. The 
young and middle-aged are generally the victims of the disorder, 
though cases are reported between the first year of life and advanced 
age. Unquestionably the predisposing causes of the affection are r 
rheumatism and the climatic changes to which rheumatism is most 
often attributed ; as well as all neurotic states due to emotional in- 
fluences, grief, anxiety, etc.; traumatisms by friction, blows, and 
direct injuries of nerves; blisters; exposures to the direct action of 
the sun ; and obscure disturbances of the nervous centre which are 
difficult to appreciate. In one of the author's cases, a young woman 
with a series of circumscribed patches along the inner face of the right 
thigh, could scarcely endure the fatigue of exposure of the part while 
an oil painting was made of the disks ; and yet another case was 
that of a muscular and hardy blacksmith, who exhibited one of the 
largest plaques of morphcea over the trunk. 

The etiological importance of the nervous system is, in the explana- 
tion of many cases, too obvious to require demonstration. This is 
much more distinct in the localized manifestations of the disorder 
where a region supplied by a single nerve or traversed by a nervous 
trunk, is solely involved. Harley, Schwimmer, and others have 
recognized cardiac and gastric disturbances ; Westphal and Eulen- 
berg, central and peripheral changes in the nervous system ; Heller 
demonstrated in one case a closure of the thoracic duct. Bancroft 3 
repeatedly recognized filarial in large numbers in the blood of a 
young girl in Australia affected with a characteristic scleroderma. 

Pathology. — The confusion which has existed in relation to the 
question of the identity of scleroderma and morphcea is due to various 
causes. By several authors similar symptoms are described under 

i Med. Chronicle, Jan. 1886. 

2 Amer. Journ. of the Medical Sciences, Oct. 1878. 

a Lancet, Feh. 28, 188C, p. 380. 



SCLERODEKMA. 473 

each of the two names ; and the symptoms described as peculiar to 
each are occasionally seen either simultaneously or successively in 
the same individual. 

Microscopical examination of the tissues involved in the disease 
has proved unsatisfactory. The connective tissue of the skin has 
been found, according to Kaposi, condensed and thickened ; its elastic 
fibres multiplied at the expense of the panniculus adiposus ; its mus- 
cular tissue hypertrophied ; the pigment in the rete and corium 
increased ; the sweat-glands dilated ; the lumen of the bloodvessels 
diminished, and their walls ensheathed in accumulations of what he 
terms " lymphatic cells. " 

Pathology. — The exact cause of scleroderma is unknown ; no 
characteristic changes in the nervous centres have yet been appre- 
ciated. In the generalized form the two vascular systems, the san- 
guine and lymphatic, exhibit within and about the walls of vessels 
embryonic cells which become converted into fibro-plastic bodies. 
This produces in parts an increase in the thickness of the tunica 
media till it is twice the normal diameter. The lumen of the vessels 
is thus obstructed, and at times obliterated, indicating that the essen- 
tial process is an endarteritis obliterans, inducing, in the areas to 
which each twig 1 of vessels is distributed, an exsanguinated state 
with a surrounding hyperemia. The latter accounts for the peri- 
pheral halo of the circumscribed forms of the malady. That there 
is at the same time lymphatic obstruction is clear, with, either from 
the one cause or the other, an overproduction of connective tissue 
and elastic fibres in the areas of involvement. The corium is com- 
monly hypertrophied, at least in the papillary layer ; while the sub- 
cutaneous tissue and panniculus adiposus are proportionately thinned ; 
and even, at times, as suggested by the clinical features noted above, 
may wholly disappear. The pigment commonly vanishes from the 
prickle layer; the coil-glands are at first dilated, and later may dis- 
appear when the atrophic stage is reached. In the late circumscribed 
forms the papillae of the corium may also fall into atrophy, and the 
superior vascular plexus of the corium undergo obliteration by 
thrombosis (Crocker). The compression of both glands and vessels 
is supposed to account for the final sclerotic and cicatriform condi- 
tion of the advanced cases. 

Diagnosis. — From the patches of vitiligo those of scleroderma are 
readily distinguished by the entire absence, in the former, of all struc- 
tural cutaneous changes and their characteristic milky-white color, the 
hairs of the part being also blanched. Both the pigmented macules 
and atrophic patches of lepra are remarkable for their anaesthetic 
condition, and their coincidence with, or sequence from, other readily 
recognized symptoms of the disease, such as tubercles, bullae, ulcers, 
and involvement of the hairs, nails, eyes, and other organs. 

In sclerema and oedema neonatorum the age of the patient would 
in general serve to distinguish the disorders, as the subjects of these 
diseases commonly exhibit symptoms long before the conclusion of 
the first year after which scleroderma is first declared. In cancer 



474 DISEASES OF THE SKIN. 

en cuirass (papillary cutaneous carcinoma), chiefly of the breast in 
women, but encountered elsewhere, the resemblance to scleroderma is 
in a high degree striking ; and I have known an eminent surgeon 
commit the error of confounding the two. In both affections the 
skin, especially of the thorax, is converted into a dense leathery 
unimpressible cuirass, but the distinction is made as follows : First, 
the carcinomatous condition of the skin may be secondary to a can- 
cerous change in the breast or nipple, in which case the doubt is 
readily removed ; second, if primary, the firm, isolated, and deeply 
tinted nodules of cancer are readily distinguished, projecting from 
the dense peripheral cutaneous infiltration ; third, the oedema and 
lymphangitis associated with the cancerous involvement are most often 
unilateral, and limited very distinctly to an arm on one side of the 
body corresponding to the side most seriously involved ; fourth, the 
line of demarcation of the cancerous change, while indeterminate on 
one side, is usually at the edge of advance distinguishable by tongue- 
like erythematous prolongations of a dull reddish hue ; lastly, the 
tendency to ulceration, the coincident and resulting cachexia, the pos- 
sible axillary adenopathy, and the relatively rapid fatal result in 
cases at all liable to be confused with scleroderma, all point to the 
truth. 

In ichthyosis the congenital history, the presence of the ichthyotic 
plates over the surface, and the general conservation of the health of 
the patient would suffice to identify the disease. 

In progressive lenticular melanoderma (angioma pigmentosum et 
atrophicum) the melanotic condition of the skin, in connection with 
warts, tumors, ulcers, and limitations of the disease to the exposed 
parts, suffice to distinguish its character. 

Treatment. — The most important consideration in the management 
of scleroderma, when either symmetrical or with a disposition to 
generalization, relates to climatic effects. Certainly more improve- 
ment is secured for these patients after their removal to a dry and 
equable climate than can be obtained elsewhere. If they must 
remain under unfavorable climatic influences, the body should be 
well protected by woolen, over muslin (lisle thread or balbriggan, 
undergarments ; and while an out-door life is desirable, such expos- 
ure should always be avoided in unfavorable weather. Internally, 
cod-liver oil, the ferruginous tonics, aud the nutrients generally are 
often indicated, as well as a roborant and generous diet. The 
employment of the iodide of potassium, arsenic, mercury, and other 
remedies, such as benzoate of lithia, the sodic bicarbonate and sali- 
cylate, and the alkalies, supposed to be indicated by the rheumatoid 
symptoms, have been praised and condemned by men of eminence on 
both sides of the Atlantic. Remedies of the reconstituent order 
should always be first employed, and no resort be had to others save 
in emergency. 

The local treatment is by baths, massage, galvanism, alternate hot 
and cold douches of the spinal column, inunctions with cod-liver oil 
and medicated salves, and the actual cautery over the spinal cord. 



ELEPHANTIASIS. 475 

The simpler is without question the better method where authori- 
ties differ. It is therefore better for most cases to employ the 
simpler inunctions, with lanolin, lard, vaseline, or combinations of 
these with a small quantity of neat's-foot oil, slightly scented ; after 
the daily salt-and-water or alkaline bath of a temperature to be 
suited to the season of the year and the physical condition of the 
patient; and to render these articles more stimulating or combine with 
them a special medicament only when improvement is not marked. 

Prognosis. — Symmetrical diffuse scleroderma well treated, results 
favorably without impairment of the general health in the most of cases. 
When atrophic changes occur, the skin may recover its suppleness 
and pliability, but this cannot be counted upon. Deformity may in 
either event complicate an otherwise favorable issue. In some, prob- 
ably not more than from one-third to one- fifth of all cases, cachexia 
or intercurrent disease closes the history. 

In circumscribed patches (morphoea) the majority recover without 
serious consequences ; the few go on to sclerosis of subcutaneous 
structures and consequent deformity. For the most of the cases of 
the last order, the disease from first to last seems to have but a local 
significance. 

Morvan's Disease (Analgesic Paralysis of the Upper Limbs, 
with Whitlow), first described in 1883, properly belongs to the field 
of general medicine. Its lesions must, however, be differentiated 
from scleroderma of the fingers. The symptoms of the disorder, as 
given by Morvau and Charcot, are : pain ; paralysis with analgesia 
of one side, then of another (occasionally the paralytic and anaes- 
thetic symptoms precede the occurrence of pain) ; lastly, whitlow of 
the fingers. These last-named lesions begin with heat, redness, and 
swelling of the skin, which may stiffen the fingers and eventually 
destroy the distal phalanges. The duration of the disease is long, its 
etiology obscure, and its prognosis grave. It is believed to be a 
special type of syringomyelia. 

Elephantiasis. 

Gr., kletyaQ, elephant. 

(Elephantiasis Arabum, Pachydermia, Bucnemia Tropica, 
Elephant Leg, Barbadoes Leg.) 

Statistical frequency in America, 0.046. 

Elephantiasis is a chronic disease of the cutaneous and subcutaneous tissues, 
usually limited to certain regions of the body, preceded by the occurrence of 
some inflammatory process in the blood- and lymphatic vessels of the affected 
part, and resulting in an enormous increase in its volume, with hypertrophy of 
the structures of which it is composed. 

Under this title has been included a group of disorders differing 
both as to their essential cause and nature. On the one hand are to 
be recognized those due to obstructive embarassment, simple or even 



476 



DISEASES OF THE SKIN, 



mechanical in character, of either the venous or lymphatic circula- 
tion ; and, on the other, obstructive embarassment due to the presence 
in the vessels of a parasite, the filaria sanguinis hominis. The 
symptoms of the two are for the present considered together. 

Symptoms. — The disease is more common in the tropics, where it 
is usually of parasitic origin ; but sporadic cases are of occurrence 
in all countries and not very rare in portions of the United States. 
Its most frequent seat is the lower extremity of one side, where the 
foot and leg, though also the thigh of the same limb, may enlarge. 
The penis and scrotum of the male, the labia and clitoris of the 
female, the upper extremities, the face, and portions of the trunk 
may likewise become involved. 

The disease is insidious in its approach, and remarkably chronic 
in its career. Usually, localized inflammations precede, as an ery- 
sipelas or a dermatitis, with or without some involvement of the 
lymphatic vessels and glands. At the same time there is a condition 

Fig. 57. 




Elephantiasis of the foot and leg. 

of general fever. To this succeeds a defervescence, with abatement 
of the local inflammation ; its sequelae becoming manifested in a more 
or less persistent oedema of the part lately inflamed. After intervals 
of days, weeks, or months, the pyrexia recurs with still greater 
involvement of the swollen tissues which, with each access of fever, 
increase in volume and gain in density. When the elephantiasic 
condition is fully developed, the skin is found to be tense, glossy, 
and blanched or discolored in various shades. Pressure upon the 
cedematous part is followed by pitting, but the tissue beneath is felt 
to be brawny and indurated. The parts beneath the skin are per- 
ceptibly increased in volume, especially the subcutaneous tissue ; and 
the circumference of a limb thus diseased may be several times larger 
than that of its fellow. A lymphangitis is usually declared by 
painful, cord-like, linear indurations of the part, associated with 
adenopathy of the nearest ganglia. In older cases, the skin loses its 



ELEPHANTIASIS. 



477 



glabrous aspect, and exhibits eczematous, verrucous, papillomatous, 
seborrhoeic, and even iehthyotic changes. Pigmentation, even to a 
blackish tint, may ensue ; scaling, Assuring, and furrowing are com- 
mon ; and the accumulation of altered sweat and sebum in these 
depressions is the source of an offensive stench. During the course 
of the disease almost all of the elementary lesions of the skin may 
be displayed by the skin, maculae, vesicles, papules, tubercles, pus- 
tules, blebs, ulcers, crusts, scales, excoriations, and fissures. Warty 
growths form as large as those seen in ichthyosis hystrix, and in 
some cases reddish-colored tumors spring from the hypertrophied 
integument. 

When fully developed in the lower extremity, the unwieldy limb, 
with the foot, ankle, and leg massed into one huge, cumbrous 
cylinder, bears a striking resemblance to that of the elephant, from 

Fig. 58. 




Elephantiasis scroti. 



which circumstance the malady first received its name among the 
Arabs. Locomotion is then greatly impeded, or rendered impossible. 
No less striking is the similar deformity of the genital labia of women 
or the scrotum of the male, the latter at times hanging far below the 
knees. In its rugous folds the penis disappears, and the urine is 
passed along a gutter formed of skin transformed into quasi-mucous 
membrane. As a consequence of the fissures and excoriations which 
form, the lymphatic channels are finally opened, and a true lym- 
phorrhoea results. After similar processes the ear may become largely 
pendulous by the side of the neck. 

Subjectively, the disease may be regarded as productive of less 
discomfort than would be suggested by its formidable features. Pain 



478 DISEASES OF THE SKIN. 

is occasionally experienced, and, during the exacerbations accompa- 
nied by pyrexia, there is corresponding malaise. The chief subjective 
sensations are those induced by the weight and consequent tension, 
inseparable from the enormous masses of hypertrophied tissue. 

In elephantiasis of the scrotum there are frequently symptoms of 
irritation, both systemic and in the vicinity of the affected part 
(nausea, vomiting, inguinal pain, epididymitis, effusion into the sac 
of the tunica vaginalis, inflammatory swelling of the spermatic cord, 
and at times hernia). In some cases vascularization of the surface 
(Telangiectasic Elephantiasis) is a prominent feature. The form 
described below as Nsevoid Elephantiasis may belong either to the 
same category, or to others in which there is lymphangiectasis 
(" lymph tumors/' " lymph scrotum"), and these either due to 
lymphatic obstruction or to the parasite described later as of etiologi- 
cal importance in this connection. 

Lymph Sceotum, Varix Lymphaticus, or Nsevoid Elephantiasis, 
fully described by Wong, Carter, Fayrer, Manson, 1 and other East 
Indian observers, is that condition in which the inguinal and femoral 
glands become large and soft, and the scrotum covered with vesicles 
and distended with dilated lymphatic vessels all filled with coagu- 
lable lymph. As in elephantiasis of other organs, there may be 
preceding fever, chills, erysipelas, and other localized inflammations. 
The disease is produced solely by the filaria sanguinis hominis, and 
may be associated often with chyluria on the one hand, and elephan- 
tiasis of other organs on the other. 

Cases occasionally reported of hypertrophy of one-half of the 
face are also to be assigned to the group of maladies to which the 
name elephantiasis is applied, excluding the parasitic and lymphan- 
giectasic varieties. Kiwall's case, a girl eighteen years old, with an 
enlargement extending from brow to throat and involving the right 
side of the tongue as w T ell as the bones and other soft parts, is an 
example of this anomaly. Crocker, Hebra and Kaposi, Barwell, 
and others report similar instances. One coming under my observa- 
tion and the subject of a skilful operation by my colleague, Professor 
Senn, suffered from a marked enlargement of one side of the face, 
due in part to an angiomatous and in part to a connective-tissue 
overgrowth. 

Acromegaly. — Cases of this rare form of elephantiasis are occa- 
sionally reported. A typical instance of the malady has been made 
the subject of an interesting monograph (with illustrations of the 
facial and manual deformity) by my colleague, Dr. Archibald Church, 
and Dr. William Hessert. 2 The disorder is also well illustrated by 
Waldo, 3 who describes a cachectic-looking male patient, aged fifty-four 
years, with enlarged hands, fingers, and knee- as well as other joints, 
which, as a result, were so clumsy as to prevent the management of 

1 Hirsch, Handbook of Geog. and Hist. Path., London. 1885, p. 328. 

2 Med. Eecord, May 6, 1893 (reprint). 3 Brit. Med. Journ., Mar. 22, 1890. 



PLATE IV. 




ELEPHANTIASIS TELANGIECTODES OF THE UPPER LIP 
AND PORTIONS OF THE FACE. 



From a photograph of one of the author's patients. 



ELEPHANTIASIS. 479 

his person. The hands looked like paws ; the fingers were enlarged in 
all proportions, the joints apparently not more involved than other 
parts. The ilia, zygoma, and arches of the orbit were also thickened. 
There were coincident symptoms of bulbar paralysis with convul- 
sions and a fatal result. Post mortem, cavities were found in the 
brain and kidneys, calcareous changes in the tissue of the cardiac 
valves, and caseating masses iu the lungs. 

Etiology. — The causes of elephantiasis are different in the several 
disorders grouped together under this title. "Wucherer, Lewis, and 
Manson have demonstrated in cases prevalent in the East and West 
Indies, Egypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, 
Mexico, and parts of China, the presence in the blood of the filaria 
sanguinis hominis. Embryos and filaria are found adhering to the 
walls of both lymphatic and bloodvessels in elephantiasis of the 
tropics. 

Other disturbances due to the same parasite and only in part 
recognized as elephantiasic, are the lymph-scrotum described above, 
chylous abscesses, effusions, and vascular and hypertrophic enlarge- 
ment of tissue and glands in and about tumors of the sort recognized 
as parasitic. 

In other cases different causes are to be recognized. Predisposi- 
tion of races or individuals, heredity, climatic influences, malaria, 
fatiguing labor with the feet and legs immersed in water, and filth 
in connection with " misery/' have all been cited as favoring conditions. 
To these should be added the local disorders especially common in 
the lower extremities, which have in cases proved to be the points of 
departure of the elephantiasic hypertrophy, such as obstruction to the 
blood or lymphatic currents by pressure of tumors, pregnancy, or 
neoplasms ; ulcers, cicatrices, and traumatisms by pressure or fric- 
tion ; cutaneous diseases ; systemic affections (syphilis, tuberculosis) ; 
and osseous disease. 

Pathology. — Even macroscopically, the elephantiasic mass is seen 
to be built up of hypertrophic elements representing all the tissues 
of which the part is composed. The knife with difficulty divides 
the homogeneous, whitish, and lardaceous mass, from which on 
pressure exudes a fluid of similar color. The subcutaneous connec- 
tive tissue is found relatively much more enlarged and sclerosed than 
the epidermis and derma ; though when the section is made through 
the rugous and warty skin described above, all the elements of the 
papillary layer, rete, and stratum corneum are seen to participate in 
the changes described in connection with the pathology of verruca. 
Here and there are loculi filled with a fluid lymph. The sheaths of 
the bloodvessels, lymphatics, and nerves, the bones, muscles, and 
aponeuroses are also thickened, solidified, and occasionally aggluti- 
nated, so as to be almost indistinguishable in the mass of uniformly 
sclerosed tissue. The pigmentation of the derma is marked ; the 
nuclei of the connective-tissue cells are multiplied ; and the cutaneous 
glands intact, hypertrophied in their epithelial linings and invest- 
ments, or, at a later stage, atrophied. 



480 DISEASES OF THE SKIN". 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands 
and vessels, the whitish and yellowish lymphatic fluid which then 
accumulates in the tissue, resulting from obstruction of the lymph 
channels. In some of the remarkable cases on record the lymphatic 
obstruction is the prominent feature of the disease ; and the elephanti- 
asic enlargement subordinate in gravity to the former condition. 
Such are, for example, the noteworthy instances in which the lymph 
distends multiple cutaneous vesicles, after rupture of one or more of 
which that fluid streams away to a dangerous extent. For a fuller 
description of this interesting class of cases the reader is referred to 
Busey's careful monographs on Occlusion and Dilatation of the Lymph 
Channels. 

Diagnosis. — The striking deformity which characterizes elephanti- 
asis will always suffice for its recognition. In the earliest stages of 
the disease, when merely an erysipelatous or eczematous condition of 
the skin can be determined, it would be difficult, if not impossible, 
to decide as to the future of the disorder, especially in a locality 
where only sporadic cases occur. A symmetrical hypertrophy of 
both legs and both feet, developing in this country, even though 
described as " elephantiasis," should be most carefully studied before 
a diagnosis is made of the particular disease here considered. The 
same might even be said of elephantiasis of but one inferior extremity. 
The author was once requested to examine a patient with extensive 
deforming induration and enlargement of the right leg and foot, ac- 
companied by pigmentation and a well-marked warty condition of the 
skin, who had been pronounced the victim of idiopathic elephantiasis 
Arabum. It was discovered that the patient had had a fracture of 
the upper third of both bones of the same leg during the previous 
year, and had since constantly worn a tight bandage encircling the 
limb at the seat of the injury. The deformity rapidly disappeared 
under the application of a roller bandage extending from the toes 
upward. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women — most commonly the labium majus of one side — 
results from a tertiary, syphilitic, gummatous infiltration which must 
be distinguished from elephantiasis. In such cases the history of the 
patient and the relative inferiority as to bulk of the affected organ, 
point to the nature of the disease. The syphilitic labium rarely ex- 
ceeds the size of a large fist. 

A gigantic hypertrophied mass of elephantiasic type is occasionally 
to be discovering in the lower extremity of one side only in women 
who have been for many years the victims of an unrecognized and 
long-untreated syphilis. Even when the leg is many times its normal 
size and weight and its contour lost in the thickened and roughened 
epidermis resembling the bark of a tree, the diagnosis may be made 
by discovering, here and there in the depth of the mass, circular and 
characteristic scars of healed gummatous ulcers. 

Treatment. — In the early stage of elephantiasis the febrile condi- 



ELEPHANTIASIS. 481 

tion of the patient and the localized cutaneous inflammations are to 
be treated by the measures appropriate for the relief of these condi- 
tions. Quinine, especially in malarial districts, is of the highest 
importance. When the elephantiasic development is established, if 
the genitals are involved, the knife of the surgeon offers the best 
prospects. The result of such interference, both in the genitalia and 
extremities, has been in many cases brilliant indeed, though the 
mortality of such severe operations is necessarily great. When the 
lower extremity is involved, it should be maintained in a horizontal 
position, its ulcers if possible healed, its excrescences removed, its 
circumscribed inflammations resolved, and then elastic compression 
be carefully and skilfully maintained by means of the rubber 
bandage. The toes are first separately enveloped ; then the foot 
and ankle ; and lastly the leg. The results are sometimes highly 
satisfactory. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg have been occasionally followed by transient im- 
provement. Instrumental compression has at times resulted in 
severe ulceration, and a reawakening of the erysipelatous affection. 
Multiple punctures and incisions, made with a view to giving exit 
to the fluids contained in the mass, have been attended by no greater 
success. The main obstacle in all these surgical procedures is the 
lymphangitis which so frequently complicates the situation. None 
of them promises so well as nerve stretching, which, in a few isolated 
cases, has been followed by noteworthy results. Excision also of a 
portion of the sciatic nerve has been followed by satisfactory changes. 
The use of the galvanic current has, when long continued, accom- 
plished resolution of engorged masses of tissue. Elastic compression 
in the horizontal position for all cases not warranting nerve stretch- 
ing, may be regarded as the wisest course when the extremity is 
involved. For the local treatment of the pachydermia proper, green 
soap, mercurial ointment, and bathing in hot or cold lotions, may be 
advantageously employed. For patients whose disease is acquired 
in countries where the deformity is prevalent, a change of climate is 
of the highest importance ; and, having in view the social surround- 
ings and habits of most victims of the disease, it is scarcely necessary 
to call attention to the need of a proper hygiene, diet, and tonic 
regimen. 

Prognosis. — The future of a patient affected with the disease may 
be regarded as most favorable when the latter exhibits an early 
tendency to respond favorably to appropriate treatment, and when 
circumstances permit of a resort to the best therapeutic measures 
which can be adopted, such as change of residence, persistent and 
careful dressing of the affected part, and the removal of any exciting 
cause of the disease, such as a neoplasm, indurated cicatrix, etc. In 
the severer cases, a fatal result may be precipitated ; but usually life 
is prolonged, burdened by the inconvenience of the enormous ele- 
phantiasic mass in comparison with which the rest of the body often 
seems to serve as a mere appendage. 

31 



482 DISEASES OF THE SKIN. 

Rosacea. 

Lat,, rosa, rose. 

Kosacea is a chronic cutaneous disorder, chiefly of the face, characterized by 
irregularly disposed, rosy or reddish maculations, often produced by acquired 
telangiectasis of the skin capillaries, or forming split-pea sized and larger 
hypertrophic nodules most commonly seated upon or about the nose. 

The condition of telangiectasis described under this title is almost 
identical as regards its clinical features with acne rosacea (Gutta 
Rosea, Copper-nose), to the chapter on which the reader is referred. 
In what follows, it is attempted to portray the affections of this class 
which may be properly described as hypertrophic in character ; rele- 
gating the acneiform cases to the chapter devoted to Acne Rosacea. 



[A.] Erythematosa. 

Symptoms. — The eruption is usually displayed in middle life or 
later, and chiefly upon the face of both sexes. In these, the nose 
(tip, alee, root), brow (especially near the root of the nose), chin, 
cheeks, temples, or lips, may be the seat of reddish or rosy blotches. 
The effect is a marked unsightliness, for which chiefly, or only, the 
advice of the physician is sought. These maculations are usually 
unproductive of subjective sensations, or of objective feeling of heat. 
They may be so numerous as to implicate all the regions named above 
to a great degree, or be limited to one or two adjacent regions, or, 
lastly, be spread very profusely over the entire face in minute blem- 
ishes not more developed at one point than another. 

The very greatest irregularity may be noted as to their contour, 
the spots being pin-point to nail-sized, roundish, radiating, stellate, 
linear, tortuous, or in any fantastic outline. The colors vary from a 
delicate rosy pink to a deep purplish crimson. Viewed with care, all 
are seen to be produced by a double process of dilatation and new 
formation of the skin capillaries. 

This condition is subject to marked aggravation, or at least tran- 
sient change of features, after the operation of any cause tending to 
congest the vessels of the head, such as stimulation by food or drink 
or both, coughing, laughing, sneezing, active exertion, the application 
of hot water to the surface, exposure to the sun, etc. After such 
occurrence, the blood will visibly distend the vessels of the face, the 
color deepen and spread, and all features of the disorder become 
decidedly conspicuous. Often a coexisting acne or seborrhcea fluida 
faciei participates in these changes. The disease is seen with almost 
equal frequency in both sexes, but women rarely exhibit the succeed- 
ing stage of the disorder, next described. 



ROSACEA. 483 

[B.] Hypertrophica. 

After a longer or shorter persistence of the condition described 
above, a new formation of connective tissue with cell infiltration 
proceeds pari passu with the telangiectasis. In this way small or 
large pin-head to egg-sized tumors are developed, more particularly 
about the tip or alse of the nose, reddish or purplish in color, till the 
stage is reached which is elsewhere described as rhinophyma. The 
absence of inflammation is in these cases marked. The nose is often 
cold to the touch when bright red in hue, and may be of a pecu- 
liarly oily or greasy appearance in consequence of a seborrhoea oleosa 
of the part. The so-called " brandy-drinker's," " wine-drinker's," 
and " whiskey-drinker's," noses are of this class. 

Etiology. — The disease in its milder manifestations is common to 
both sexes, the hypertrophic forms being rarer and practically 
limited to the male sex. The causes of the disorder are numerous, 
but always operate by producing at first active or passive distention 
of the bloodvessels of the upper portion of the body. Among these 
effective causes may be named gastric dyspepsia (especially though 
not exclusively associated with intemperate use of alcoholic stimu- 
lants, including brandy, whiskey, wine, and beer); articles of clothing, 
surgical apparatus, tumors, etc., compressing the larger vessels at the 
root of the neck ; the long-continued action of heat aud cold upon 
the face, as also the local effect of chemicals, and the influence of 
certain trades and occupations of life tending to produce congestion 
of the face, as, e. g., among cooks, cab-drivers, swimming teachers, 
etc. In some cases there is a distinctly inherited tendency to dis- 
tention of the capillaries of the skin of the face ; in yet others, the 
rosaceous blemish is congenital. Diseases of the uterus and other 
viscera may be the remote sources of the trouble. 

Pathology. — The hyperemia usually begins as a transitory phe- 
nomenon in the more deeply seated plexus of vessels, and, after per- 
manent distention has resulted, the vascular elements of the more 
superficial strata of the corium and those surrounding the sebaceous 
glands and hair-follicles become involved. In the hypertrophic 
lesions, there are: new formation of connective tissue, enlargement of 
all portions of the corium, hyperemia and telangiectasis of the ves- 
sels, and dilatation of the sebaceous glands. 

Diagnosis. — Acne rosacea is to be distinguished from uncompli- 
cated rosacea by the characteristic lesions of the former, comedones, 
papules, pustules, crusts, etc. In uncomplicated rosacea, there is 
only a macular lesion due to hyperemia or telangiectasis. The two 
disorders, thus artificially distinguished, are often found the one 
complicating the other, an acne being the origin of the hyperemia, 
which is the first rosaceous stage. The hypertrophic lesions of 
rosacea are also often thus associated with acneiform symptoms. 
Lupus, carcinoma, and syphilis of the regions affected by rosacea, are 
commonly productive of ulcerative or destructive consequences which 
point to the nature of those affections. 



484 DISEASES OF THE SKIN. 

Treatment. — The treatment of rosacea is practically the same as 
that of acne rosacea, to the chapter devoted to which the reader is 
referred. The vessels producing the rosaceous blemish are to be 
destroyed, preferably by electrolysis; but the result may also be 
accomplished less elegantly and perfectly by incisions, followed by 
cauterization ; by curetting ; by the Paquelin knife ; by Brun's sharp 
spoon ; VidaPs lancet ; or the multiple scarificator — the last-named 
instrument being only available for the larger lesions. The hyper- 
trophic forms of rosacea are best remedied by the plastic operations 
of modern surgery. 

Prognosis. — The lesions of rosacea, limited in extent, even though 
quite numerous, may be elegantly and permanently removed by 
electrolytic methods. The scars left after operations upon the larger 
lesions are usually superficial, and not disfiguring. The prognosis, 
after ablation of the largest hypertrophic lesions, is proportioned to 
the resources of surgery. In no case does general disease result. 



Frambcesia. 

¥i\, framboise, raspberry. 

Frambcesia is a disease of the African race chiefly, manifested in pin-point to 
egg-sized and larger papulo-tubercular lesions, appearing mostly on the face, 
resulting in discharges and crusts, and in cases followed by systemic symptoms. 

This disorder, termed by Charlouis, Polypapilloma Tropica, is 
encountered chiefly among the negroes residing along the African 
coasts, in the West Indies, and in South America, where it is also 
known as Yaws and Pian. By Alibert it was termed Mycosis 
Frambcesioides. The contributions to the literature of this sub- 
ject have been made chiefly by Drs. Milroy, Nicholls, and Imray, of 
Dominica, and Dr. Bowerbank, of Jamaica. The malady is char- 
acterized at first by the occurrence of brownish-red, pin-head to 
to pea-sized, flat maculo-papules. In these, one or more yellowish 
or whitish puncta become visible, which gradually develop into 
roundish papules or tubercles, resembling pea-sized and larger pus- 
tules of yellowish-red color. When the integument which covers 
these gives way a fetid, sero-purulent fluid exudes, and a dirty- 
yellow T ish, spongy mass projects from the rent, and enlarges subse- 
quently, till it appears as a yellowish-red, crusted vegetation, an inch 
or more in diameter. This may degenerate into an offensive ulcer, 
whose destructive processes are accompanied by progressive emacia- 
tion and systemic disturbance. Instead of this retrogressive meta- 
morphosis, the tubercle may shrivel into a dark-colored, crusted, and 
withered excrescence, yielding a fetid and ichorous discharge. The 
eruption occurs upon the face, neck, extremities, ano-genital region, 
and, rarely, upon the trunk. 

The lesions are seldom the seat of subjective sensation. They 
have been considered contagious, and not susceptible of transmission 
by heredity. The course of the disease usually occupies from two to 



FRAMBCESIA. 485 

four months. It is also said to occur at all ages and in both sexes, 
one attack conferring immunity against another. 

The constitutional symptoms of the malady include fever, osteo- 
copic pains, gastro-intestinal distress, arthritic troubles with ulcera- 
tions about the joints resulting in deformity, and eventually cachexia. 

The disease is both inoculable and auto-inoculable. Inoculation 
results in the formation of a crust-covered ulcer, followed in from 
seven to fifteen days by a general eruption. The result is rarely 
fatal, the disease being concluded in most cases after a period of from 
three to four months' duration. 

Most of the authorities who have personally studied the disease as 
it occurs in the African race believe that frambcesia is a disease sui 
generis. Certain it is that in both syphilitic and non-syphilitic sub- 
jects, who have never visited the countries where it is claimed that 
the disease is endemic, similar symptoms have been recognized and 
described. An interesting case of framboesioid lesions in a syphilitic 
woman is reported by De Amicis ;* and the author has personally 
treated three patients whose lesions corresponded very closely to those 
described above, no one of whom was syphilitic. It can be readily 
understood that a vegetation occurring upon the filthy skin of an 
unwashed negro in the tropics might assume features which would 
be scarcely recognized as classical, in the clientele of most practitioners 
in this country. 

It is safest at present to regard the term frambcesia as largely 
descriptive in scope, and as including certain papillomatous and other 
vegetations projecting from the surface of the body as a result of 
filth, syphilis, tropical temperatures, and possibly of other unfavor- 
able agencies operating upon the skin of a negro. A sufficient com- 
mentary upon these considerations is afforded by the admission of the 
West India surgeons, that mercury and the iodide of potassium are 
regarded as specifics for the disease as it exists in those islands, and 
that cleanliness is of prime importance. 

Parangi. 

Kynsey has presented a report upon the nature of the disease 
which is thus designated in Ceylon, where it prevails. It appears 
to present mixed features of syphilis, land scurvy, yaws, pellagra, 
lupus, leprosy, scrofula, and less severe disorders, existing as an 
endemic in certain provinces of the island. It is clear, from the 
description of the symptoms recorded, that the nature of the disease 
has not yet been recognized. It was first described by Loos in 1868, 
and is now regarded as due to numerous causes, such as malnutri- 
tion induced by impure food and water, wretched hygienic surround- 
ings, and infection from the discharges from ulcers. 

There is, according to Christie, 2 an incubation period of from two 
to eight weeks, followed by the appearance of an ulcer over any bony 
prominence — the initial sore. This is followed by malaise and 

1 Cf. a translation of his paper by the author in the Archives of Derm., October, 1879, p. 39. 

2 See Anderson's Treatise on Diseases of the Skin. 



486 DISEASES OF THE SKIN. 

pyrexia, the premonitory fever lasting from two to eight days, and 
followed by the exanthem which appears first over the face, and later 
on the body. This eruption may be vesicular, pustular, pustulo- 
tubercular, or squamous, superficial ulcerations forming which become 
subsequently crusted. Eupioid, furuucular, and psoriasiform features 
are common in the course of the malady. Condylomata may appear 
at the anus. Ulcerations succeed later of a more formidable char- 
acter, involving the nose, palate, and cheeks ; the digits may be lost 
by gangrene ; blebs occur ; pricking pains are experienced ; there 
may be anaesthesia of some part of the surface, associated with bronz- 
ing and glazing of the skin. The patient may perish of some inter- 
current disorder or from exhaustion. 

The duration of the disease is said to be from two to eight years. 
Treatment has been successful with the cautious employment of mer- 
cury and the iodide of potassium, and strict observance of the rules 
of hygiene. 

Donda Ndugu ( (i brother ulcer," or " ulcer that clings "). 

is a disease existing in Central and Eastern Africa. Dr. James 
Christie, 1 who first described it, believes it to be identical with that 
from which. Livingstone suffered in 1870. 

The disease is confined to the lower extremities, and occurs among 
the natives chiefly in the rainy season after a march toward the 
coast. 

It is characterized by the appearance of whitish papules springing 
from a boggy swelling, seen often near the toes, heel, or dorsum of 
the foot. When incised, an extensive, deep-seated slough is found 
beneath the healthy tissue, bathed in an ichorous discharge. Severe 
rapidly-spreading ulcerations and death may ensue. Livingstone ex- 
tracted the ova of a species of maggot from such lesions in his own 
person ; but Christie failed to discover them in his cases. The treat- 
ment is local, by the use of antiseptics after incision. 

Verruga Peruana. (Peruvian Wart.) 

This is a specific disease, both endemic and at times epidemic, 
occurring for the most part in the mountains of Peru, and commu 
nicable by inoculation. There is a prodromic febrile stage, followed 
by the appearance on the skin of maculo-tubercular, softish, tender, 
and hemispherical tumors, which may attain the dimensions of a 
small or large nut. Hemorrhagic effusions occur as a result of fis- 
sures in the epidermis covering the lesions, at times incoercible and 
leading to fatal anaemia in severe cases. The lesions may be few or 
numerous ; occur on the several parts of the head and extremities 
(rarely on the trunk), and may eventually be desiccated or break 
down into ulcerations. A fatal result may occur at any stage from 
haemorrhage, or the disease be relieved in the course of a few months. 

1 See Anderson's Treatise on Diseases of the Skin. 



LEUCODERMA. 487 

It is said to attack the whites more often and with greater severity 
than the negroes. 

Hirsch 1 and others have described the disease, an excellent outline 
of which is given by Crocker, who states that the mortality is from 
6 to 10 per cent, among the natives; and from 12 to 16 among the 
whites ; or, in epidemics, 40 per cent. Bacilli have been recognized 
supposed to be the cause of the disorder. 



CLASS y. 

ATROPPHIES. 

1. Of Pigment. 

Absence of the pigment of the skin, giving rise to conspicuous 
disfigurement, is naturally most frequently encountered in those 
races of mankind whose skins are most abundantly provided with 
such pigment. The absence of pigment may be congenital or ac- 
quired, and partial or universal. Some confusion has been produced 
by the arbitrary distinction established by authors between the names 
intended to designate these several varieties of achromatia or leuco- 
pathia. In the following pages, leucoderma is the name employed 
to designate the pigment atrophy which is partial and congenital ; 
albinismus, that which is universal and congenital ; vitiligo, that 
which is acquired. 

Leucoderma. 

Gr., ^mof, white ; dep/ua, skin. 

(Achroma ; Leucasmus.) 

Statistical frequency in America, 0.062. 

Leucoderma is a partial congenital absence of pigment in the skin, most com- 
monly observed in the colored races, and characterized by whitish patches or 
bands having an irregular border, the evidences of disease in such parts being 
limited to the changes in hue of the skin and hairs. 

Symptoms. — In these cases, the patients being most often of the 
colored races, one or several whitish or rosy-whitish patches or 
bauds, varying as to size, outline, or situation, may be seen at birth 
unprovided with pigment. These may have a symmetrical arrange- 
ment, in which case they commonly observe the areas of distribution 
of one or more cerebral or spinal nerves, or be asymmetrical in dis- 
tribution. They are usually of circular outline, and may be found 

1 Handbook of Geog. and Hist. Pathology, vol. ii, p. 114. 



488 DISEASES OF THE SKIN. 

upon the scalp, face, nipples, breast, and genital region. The hairs 
found upon such parts are equally destitute of normal color, being 
usually white. Negroes thus marked are generally termed " pie- 
bald/ 7 and the integument similarly affected in persons of other 
races has long been recognized as the " pied " or " piebald skin." 
These blemishes, when symmetrical, like pigmentary nsevi, exhibit a 
striking analogy with the symmetrical arrangement of the spots, 
bands, and stripes to be recognized in the furs of many of the lower 
animals. The outline of the patch may be abrupt, or may gradually 
shade into that of the adjacent integument. At times, islands of 
pigmented skin are visible within the non-pigmented areas. The 
changes in these patches during later life may be insignificant, or 
they may individually increase in size with age, or even multiply. 
Rarely they regain pigment in later life. In no case is there an 
excess of pigment deposited at the border of the patch. 
This condition is practically remediless. 



Albinismus. 

Lat., albus, white. 

Statistical frequency in America, 0.008. 

Albinismus is a congenital cutaneous achromia, characterized by universal defect 
of pigment, unaccompanied by textural changes in the skin. 

Symptoms. — The term albinismus is here limited to the congenital 
conditions of achromia induced by universal failure of cutaneous 
pigment. 

This deformity is peculiar to individuals known as albinoes 
(Kakerlaken, Dondos), isolated instances of this anomaly occurring 
in all races, but more frequently among those having normally a 
hyperpigmentation of the skin, such as negroes. In the subjects of 
this anomaly, the skin has a milky-whitish, transparent, or rosy- 
tinted hue, and is usually of delicate texture; the hairs are silky and 
yellowish, whitish, or snowy-white in color; the iris, transparent or 
pinkish ; and the pupil, in consequence of the defect of pigment in 
the choroid, is also reddish or pinkish. There is, as a result, nycta- 
lopia and heliophobia with frequent nictitation, pupillary variations, 
and the semblance of myopia. 

The pinkish hue of the skin is, in these individuals, due only to 
its trauslucency and vascularity. In no other respect, save as to 
pigment anomaly, does the skin of the healthy albino indicate dis- 
ease ; but the majority of persons thus deformed are far from vig- 
orous. 

In albinismus the defective condition of the pigment is usually 
unchanged throughout life. It has been observed that some albinoes 
are physically inferior to the average of persons of the same sex, 
both in stature, weight, mental activities, and powers of resistance 
to disease. There are, however, numerous striking illustrations of 



VITILIGO. 489 

the reverse of this, and the author has had under observation a 
number of albinoes in one family where alternations of non-pig- 
mented with normally pigmented children exhibited no difference 
whatever in sturdiness and vigor. Many of the enfeebled albinoes 
are simply illustrations of the wretchedly unwholesome life of per- 
sons imported for exhibition to foreign countries. 

Etiology. — Inheritance is a frequent cause of this and similar 
pigment anomalies. The author has observed several members of 
one family affected with albinism and many such are on record. 
Alternations of white and black children born in one family have 
been recorded also by other observers. 

The condition is remediless ; though it is probable that transfusion 
with the blood of a vigorous black-skinned African would largely 
modify the color characteristics of the pure albino. 



Vitiligo. 

Lat., vitium, a blemish. 

Statistical frequency in America, 0.155. 

Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, vari- 
ously shaped and sized patches, unaccompanied by textural change in the skin, 
and usually bordered by tissues exhibiting pigmentary excess. 

Symptoms. — The disorder is one observed among the several races, 
often in the negro, and not rarely among those of Aryan descent, It 
commonly occurs without the slightest appreciable disorder, subjective 
or objective, save that betrayed to the eye in the discoloration of the 
skin. One or several roundish, or very irregularly shaped, smooth, 
and well-defined, pale, or milky-white lines, streaks, or disks appear, 
often bordered at the periphery by an integument which assumes a 
light or dark brown or chocolate shade, this hue being by contrast 
most noticeable immediately at the contour of the patch, and imper- 
ceptibly fading into the normal color of the outlying integument. 
The hairs or lanugo filaments growing from the affected area may or 
may not be blanched. Most commonly they are ; a condition par- 
ticularly conspicuous when, as is not rarely observed, a vitiliginous 
disk extends from the back or side of the neck, well into the scalp, 
in which case the outline of that portion of the scalp involved is 
clearly defined by the whitened pilary growth. 

Lesser describes a condition termed by him "Poliosis Circum- 
scripta Acquisita," in which the hairs were thus blanched in a single 
area of an unaffected scalp, an observation which the author has con- 
firmed in a single case. 

The surfaces thus blanched are otherwise unchanged. In point of 
subjective and objective sensations, secretion from the follicles, and 
the condition of both epidermis and corium, aside from the dyschro- 
mia there is no departure from a normal standard. The disease 



490 



DISEASES OF THE SKIN. 



Fig. 59. 



may progress by the coalescence of relatively small affected areas 
till a large portion of the trunk, thigh, or buttocks is involved. 
Hall 1 reports the case of a dark mulatto who became "perfectly 
white " with the exception of a patch on the chin. Levy 2 reports 
three instances of total disappearance of pig- 
ment. It is then, as Kaposi has well shown, 
that the eye of the observer is struck no 
longer by the unusual whiteness of the in- 
volved patches ; but this whiteness being 
generalized and apparently that proper to the 
person, by the intermediate peripheral belts 
of a deeper and unusual color. The greater 
portion of the surface of the body may be 
finally thus involved. The most common 
seats of the disease are the face, the neck, the 
backs of the hands, and the extremities ; and 
in these, since the course of the disease is 
exceedingly slow, there may be for years no 
apparent extension of any involved area. 
Upon the backs of the hands the disfigure- 
ment is usually more conspicuous at some 
seasons of the year than at others, a circum- 
stance which probably explains the reported 
instances of recurrence and total disappear- 
ance of the disease in successive years. These 
changes are probably due to the influence of 
the sweat in washing the pigment to the sur- 
face. Such an effect would, of course, render 
the hyper-pigmented peripheral zone of a 
vitiliginous disk much the more conspicuous. 
The health of the subjects of this disorder 
is usually unimpaired. A morbid mental 
condition is often produced when the disfig- 
urement reaches the facial region, especially 
in women of middle life. 

As in several of the other pigmentary dis- 
orders of the skin, the patches of vitiligo may 
be symmetrical in distribution, with their out- 
lines limited to the areas supplied by certain 
nerves. Lesser, however, attributes this pecu- 
liarity to the symmetrical anatomical relations of the skin in sym- 
metrical regions of the body, an explanation which will not suffice 
for all cases. 

v ^.The course of the disorder is evidently toward increase even where 
all the pigment is not removed from the surface. Generally a term 
is reached beyond which the atrophy does not progress. In excep- 
tional cases the parts which have lost their pigment again acquire it. 




Vitiligo in a Negro boy. 
Piffard's case. 



i Louisville Med. News, 1880, x. p. 148. 

2 Receuil de Mem. de Med. de Chirurg. et de Pharm. mil., 1865. 



VITILIGO. 491 

Patients of lymphatic temperament and blonde complexion (often 
they are women in early adult life) will occasionally apply to a 
physician for relief of dark patches on the skin of the face. Ex- 
amination of these faces ofteu discloses faint lines, ribbons, or streaks 
of pigment about one or both cheeks, the temples, or the lips. But a 
yet more careful scrutiny recognizes an undue whiteness of the skin, 
with exceedingly faint and irregular outline near or next to these 
pigmented portions of which complaint is made. I am inclined to 
set all these cases down as instances of vitiligo, even though they 
rarely exhibit the definite roundish contour of the typical patch of 
the disease. 

In most cases the decolorized patches are most conspicuous in sum- 
mer ; in others, this occurs in winter. These peculiarities may de- 
pend upon changes either in the pigmented or unpigmented portions 
of the skin. 

Etiology. — Vitiligo occurs in both sexes, and in individuals of all 
complexions and ages; though it is commonly observed among 
women and in early or middle life. It is at times coincident with 
scleroderma, lepra, variola, and other diseases with similar cutaneous 
symptoms, though it occurs independently of all such. Its etiology 
must be regarded as obscure, unless the strong probabilities in favor 
of its occurrence under the influence of perturbed innervation be 
accepted as conclusive. I am strongly inclined to believe that the 
disorder is of more frequent occurrence than dermatological statistics 
tend to show. Many persons who are the subjects of vitiligo of an 
inconspicuous part of the body do not consult a physician with re- 
gard to the nature of the disease, as it occasions no physical distress. 
Close observation of the people with whom one comes in contact in 
public will often verify this fact. 

Pathology. — The pathological anatomy of vitiligo may one day be 
described in the changes which occur in the trophic nerves supplying 
the skin. At present, the cutaneous changes alone are recognized; 
and these are, as regards the pigment, neither strictly atrophic 
nor hypertrophic. It is true that there is an apparent atrophy 
in one portion of the skin, and an apparent hypertrophy in another; 
but this may be, in cases falling short of complete pigment atrophy, 
merely a dystrophia or ataxia of the epidermis, a disturbance 
of arrangement and distribution, as of the blood in the face, in 
certain cardiac diseases, when the skin is temporarily streaked or 
mottled by the irregularity in the distribution of the circulating fluid. 
Under the microscope no change is recognized in the skin beyond the 
absence of pigment. 

Diagnosis. — Mr. Hutchinson, of London, has devoted an entire 
chapter in his valuable Lectures on Clinical Surgery* to the impor- 
tance of the diagnosis between leucoderma aud white leprosy ; yet it 
seems incredible that the symptoms characteristic of a systemic dis- 
ease could be confounded with those described above, where there 

1 Churchill, London, 1878. 



492 DISEASES OF THE SKIN. 

is no cutaneous anaesthesia nor structural change in the integument. 
This latter is, in fact, the basis of discrimination between all purely 
pigmentary and all non-pigmentary changes in the skin-color, separ- 
ating them widely from parasitic diseases (tinea versicolor), morphoea, 
lepra, and syphilis. From the chloasmata which are always accom- 
panied by hyper-pigmentation, vitiligo is readily differentiated. 

Treatment. — Much chagrin will be saved both physician and 
patient, by practically regarding vitiligo as not amenable to treat- 
ment. Patients occasionally recover while under treatment; the 
latter has, however, generally contributed but very little to the result. 
Arsenic and iron internally, recommended highly by some authors, 
have repeatedly failed to accomplish any appreciable results as regards 
dyschromia. By efforts directed to the removal of the hyper- 
pigmentation in the border of the achromic patches, the disfigure- 
ment may be somewhat lessened. The method of arriving at this 
end is described in connection with the treatment of chloasma. It is 
possible that further experimentation with hypodermatic injections of 
pilocarpine, which have in a limited number of cases been followed 
by disappearance of the disease, may warrant a less unfavorable view 
of the results of treatment. 

Prognosis. — The health of the subject of the malady is not im- 
paired. The disease is practically incurable, progressing usually till 
it has obtained a maximum of development ; and then, as a rule, 
remaining unchanged throughout life. 



Canities. 

Lat., canus, white. 

(Trichonosis Cana, Poliothrix, Hoariness, Canities, Poliosis.) 

Canities is that condition of the hairs in which they become in various degrees 
decolorized as the result of atrophy of their pigment. 

Symptoms. — In this anomaly the hairs appear in all shades of 
whiteness, from dirty-gray to silvery- white, and this either as a 
general or partial, congenital or acquired, physiological or patholog- 
ical, prematurely, rapidly, or gradually acquired condition. General 
congenital whiteness of the hairs is seen in albinismus, where pig- 
ment has never been supplied to the filaments. Partial congenital 
whiteness is occasionally seen, in meshes limited in size, varying in 
color from a pure white to a deeper hue, which from birth refuse ta 
receive pigment in due proportion, and thus contrast strangely with 
the pigmented filaments by which they are surrounded (Vitiligo). 

Physiological decoloration of the hairs in variable shades is the 
well-known result of advancing years. When premature, it may be 
considered as resulting from pathological causes, or due to other in- 
dividual or inherited peculiarities. It may occur gradually or sud- 
denly ; in the former case, the hairs usually pass through varying 



CANITIES. 493 

shades of gray to white, and this at any period after puberty, though 
usually after middle life is reached. Eecurrence to the darker shades 
is rarely noted. Leonard, of Detroit, 1 cites a number of curious 
instances in which changes of this sort have occurred. Generally, 
however, canities of advanced years is progressive and permanent, 
occurring earliest on the temples and the beard of man, then involv- 
ing the vertex of the head. Finally, the hairs of the entire surface 
undergo a similar pigmentary loss. 

It should be remembered that the coloring of the hairs of the head 
is, to a greater extent than is commonly appreciated, subject to vari- 
ation from the operation of external causes. Thus, washing the hair 
with alkaline solutions has a bleaching effect, while profuse sweating, 
inunction with fats, subjection to smoke, and the temperature changes 
of the summer, have the contrary influence, the last named being 
possibly associated with the increased sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, in 
a single night, are sufficiently numerous and well authenticated to be 
admitted as among the rare possibilities of a clinical experience. 
Nervous disorders, both centric and peripheral, such as long-con- 
tinued mental depression, melancholia, paralysis, neuralgia, and 
traumatism of nerves or of nervous centres, may be followed by more 
or less rapid, general or partial, and permanent canities. The same 
result may follow wasting disorders, such as typhoid fever, tubercu- 
losis, syphilis, and malarial (Chagres) fever, in which cases, as dis- 
tinguished from the others, properly pigmented hairs may eventually 
replace those which, were white. It is well known that the first 
hairs springing from a patch of alopecia areata where repair is in 
progress are often white or whitish, and replaced later by those of 
normal color. 

Landois has shown that many instances of suddenly occurring 
canities depend solely upon the j*apid appearance of air-bubbles in the 
shaft, in excess of the average number. Hairs whitened in alternate 
patches, rings, nodes, or spots have been described by Landois, 
Karsch, Richelot, Spiess, and others. 

Etiology. — Whitening of the hair may be senile in origin, in which 
case it is customary to declare it to be physiological ; or be due to 
heredity ; to deficient nutrition or innervation of the hair-follicles ; 
to functional or organic nervous affections (fright, facial atrophy, 
etc.) ; or to local chemical action upon the hairs. Premature canities 
in young adults is often associated with the occupations of life, 
being much more common in men who from necessity have the head 
habitually covered, and who yet lead sedentary lives. 

Pathology. — The pigment substance of the hairs is both cellular 
and intercellular in its distribution, and is supplied by the papilla. 
Decoloration of the hairs may be due to failure of supply or removal 
of pigment ; to unevenness of the hair surface (by which the light is 
refracted) ; or to air-bubbles between and within the fibre-cells. In 

i The Hair, etc., Detroit, 1880. 



494 DISEASES OF THE SKIN. 

senile and presenile decolorations there is commonly actual diminu- 
tion of pigment, which has been ascribed to failure of the papilla to 
produce or transmit it. Sudden canities is ascribed to the sudden 
appearance of air-bubbles in quantity in the shafts of the hairs. 
Alternations of color in the hairs are ascribed to successive periods 
of activity and rest in the pigment-producing function of the follicle. 

Treatment. — McCall Anderson, while admitting that the treatment 
of canities is unsatisfactory, suggests, in cases of accidental presenile 
blanching, strict attention to the general health, arsenic internally, 
and local stimulation, as in alopecia simplex. But the chief means 
of remedying premature canities is by the action of dyes, and these 
are, in the main, compounded of solutions of nitrate of silver, 
acetate of lead, and the sulphate of iron. The chief objections to 
their use are the disagreeable coloring of the scalp which results from 
incautious use of the dye, and the consequent liability to irritation 
of the surface. When applied to the hair alone these substances are 
not known to have a deleterious effect upon the health. Kaposi 
gives the following formulae for hair dyes : 

To obtain a black color — 



or, 



H . Argent, nitrat. gr. xv ; 1 

Ammon. carb. gr. xxij ; 1 

Unguent, adipis ^j ; 32 

Be . Argent, nit. 3 j ; 4 

Plumb, acetas gr. xv ; 1 

Aq. Cologn. gtt. xv; 1 

Aq. ros. adf^iij; 96 

To obtain a brown shade — 

R. Acid, pyrogall. gr. xv; 1 

Aq. Cologn. gss; 2 

Aq. ros. Jjss; 48 



M. 



M. 



M. 



Anderson first applies a lotion of the bichloride of mercury, two 
grains to the ounce (0.133 to 32.), and follows this with a solution of 
the hyposulphite of sodium, one drachm to the ounce (4. to 32.), for 
the production of a jet-black shade. 



2. Of Hair. 

Alopecia. 

Gr., aluirr]^ a fox. 

(Alopecia, Calvities, Defluvinm Capillorum, Deficiency of Hair, 
Baldness. Gee., Kahlheit. ) 

Alopecia is a physiological or pathological, symmetrical or asymmetrical, partial 
or complete deficiency of hair. 

This condition may be due to arrested pilary development at 
birth, or to any cause interfering with the regular physiological pro- 



ALOPECIA. 495 

cess by which hairs are constantly shed and replaced by new fila- 
ments. 

The simple term, alopecia, is no longer descriptive of a disease, 
but only of a symptom, loss of hair, which occurs in a large number 
of morbid and even physiological states. The classification of these 
with respect to alopecia is differently planned by different authors, 
but the most are substantially agreed upon the following divisions : 
In a first class are named the forms of baldness depending upon 
general conditions of the system, physiological or pathological; 
among the former are the congenital, presenile, and senile varieties ; 
among the latter those due to all causes producing debility, anaemia, 
and defective nutrition. In this last group are named the alopecias 
of tuberculosis, erysipelas, syphilis, carcinoma, diabetes, and malarial, 
chemical, and other intoxications. 

In a second class are included the alopecias due to local scalp 
affections, including two groups ; those, first, in which the baldness 
is an epiphenomenon of the cutaneous malady (Brocq), such as the 
loss of hair incidental to pemphigus foliaceus, exfoliative dermatitis, 
scleroderma, lupus erythematosus, and pityriasis rubra. In a second, 
are those in which the hair loss is the chief morbid symptom : (a) 
alopecia furfuracea, and the group of disorders which may be repre- 
sented by that name, the seborrhceas, the seborrhceic eczemas, etc.; (6) 
alopecia areata, which eventually may be included in the first class as 
a hair loss due to centric nervous changes ; (c) an indeterminate 
and ill-recognized group, in which folliculitis is a distinguishing 
symptoms ; and (d) the alopecias due to vegetable parasites. 

Many of these several affections are discussed in the chapters of 
this work specially devoted to each. In the pages which follow, 
attention is particularly directed only to those special forms of alope- 
cia, usually separately considered, because it is the deformities resulting 
from these for which the practitioner is most commonly consulted. 

Congenital Alopecia. — In rare cases there is a partial or com- 
plete absence of hairs at birth, in consequence of an arrested develop- 
ment of the pilary system. Generally, however, these appendages 
of the skin are merely of tardy appearance, their eruption being ex- 
traordinarily delayed, as in cases of retarded dentition. 

When this condition persists to adult years, as is very rarely the 
case, neither hairs nor teeth may be formed, as in Dauz's observa- 
tion. The author has had a child seven years of age presented at 
his clinic, with only a wisp of white hairs upon the vertex of the 
scalp. 

In localized congenital alopecia, hairs rarely develop after matu- 
rity, and here also abnormalities of teeth may be coincident features. 
In a case examined by Schede, 1 the sebaceous glands were found 
opening on the free surface of the skin. In the deeper part of the 
cutis, straight or convoluted hair-rudiments were visible in the 

1 Arch, fur Klin. Chir. Bd. xiv. 



496 DISEASES OF THE SKIN. 

tubules, without perceptible internal cavity, which corresponded to 
the external root-sheath. 

Senile Alopecia. — The baldness of old age, whether occurring 
upon the vertex, so as to produce a tonsure like that of the priest, or 
whether limited to the frontal region, or so extensive as to involve 
nearly the entire calvarium, leaving a fringe of hairs at the occiput 
and temples merely, is always remarkable for its symmetry. There 
is hence a certain degree of dignity added to the appearance of the 
head, which an asymmetrical loss of hair could not produce. It may 
occur at varying ages of advanced life, and is quite frequently trace- 
able to an early seborrhcea sicca or alopecia furfuracea. It is much 
more common in men than in women ; and this largely because of 
the difference in the manner of covering the head in the two sexes, 
women usually wearing an exceedingly light dress for the head, 
while men encase the latter with tight fitting caps or hats which 
interfere with proper aeration of the scalp. Individuals of the male 
sex, also, in consequence of their usually wearing the hair short, 
bestow far less time upon the care and dressing of it. In uncivilized 
races, where these differences are less marked, and where men pay 
great attention to the ornamentation of the scalp, senile baldness is 
of less frequent occurrence. 

The bald surface is, as a rule, smooth and shining ; it is occasion- 
ally the seat of a seborrhcea oleosa. The hair-follicles, with their 
accessory sebaceous glands and occasionally the skin itself, are often 
in a state of atrophy, though there may be dilatation of the sebaceous 
glands. There is commonly some blanching of the hairs, which are 
gradually shed, as also of those which remain, though this is not 
constant. These conditions are much less frequent upon the surface 
covered by the beard and pubic and axillary hairs, where, according 
to Michelson, the hairs in advanced years are often denser than at 
other periods of life. 

Premature or Presenile Alopecia, or premature calvities, is 
that form of acquired baldness which occurs in individuals who 
have not attained advanced years. It may be either idiopathic or 
symptomatic. 

The idiopathic variety does not originate in the diseases of the 
scalp or of the general economy which are recognized as effective in 
the production of other forms of baldness. It is, as with senile 
alopecia, more common in men then in women, and is, in the former 
sex, decidedly prevalent among those leading sedentary lives. The 
loss of hair may be produced either rapidly, or, more commonly, 
slowly, and at any period after the puberal epoch. The pilary 
growth may gradually and evenly recede from the forehead, or, what 
is more frequent, recede on either side of the median line, leaving a 
more vigorous crop extending centrally toward the root of the nose, 
or produce the effect of the tonsure described above. It is always 
symmetrical, and usually remediless, partial calvities being the per- 



ALOPECIA. 497 

manent result of the process. In many families there is a predispo- 
sition to this premature loss of hair, which may be recognized in the 
males of succeeding geuerations. 

Symptomatic premature alopecia is the frequent result of a series 
of local aud general disorders which vary in their gravity. Sudden 
and gradual symmetrical thinning of the hairs or complete baldness, 
is sufficiently common as the result of seborrhoea sicca, psoriasis, aud 
other cutaneous affections of the scalp ; the asymmetrical forms being 
more common in asymmetrical scalp diseases, such as those resulting 
from the destructive action of the vegetable parasites. Rarely, how- 
ever, asymmetrical seborrhoea, occurring in patches upon the side 
of the head, may produce such disfigurement. Among the systemic 
disorders which have this effect may be named almost all severe 
febrile processes, including the exauthemata, profound disorders of 
the nervous centres, lepra, and syphilis. In the last-named disease it 
may occur as a precocious or tardy symptom, the former being always 
symmetrical, variable as to the degree of loss, rarely so severe as to 
cause baldness, and, occurring as it does usually in early adult years, 
generally quite remediable. The tardy form, on the other hand, 
is usually associated with the evolution or destructive involution of 
gummata of the scalp, and the resulting baldness is often permanent. 

The forms of alopecia described above as encountered upon the 
scalp, may involve also other hairy portions of the body, as of the 
axillae and pubis ; aud these also in variable degrees. 

Pathology. — In senile and premature alopecia, a fibrous endarteritis 
is described by Michelson as first occurring to narrow the lumen of 
the vessels, which starves the follicular and peri-follicular tissues till 
an atrophy results. The epidermis becomes thinned ; the derma 
contracts; the hair-follicles shrink, while their funnel-shaped orifices, 
occupied with loose horny masses or lanugo hairs, remain patulous. 
Convolutions of pigmented, roundish nuclei, aborted results of hair- 
formation, may rarely be recognized at the base of the empty hair- 
sacs. The coil- and sebaceous-glands and muscles are but slightly 
altered. 

Treatment. — The treatment of alopecia in general is that which 
stimulates the nutrition of the hair follicles by producing in its peri- 
phery a species of transitory and artificial hypersemia. This is 
usually accomplished by friction of the scalp with a brush, aided by the 
local employment of one or more of the alcoholic, oily, alkaline, and 
other stimulating applications described below. The general health 
must, in such cases, receive special attention. A large number of 
individuals suffering from premature baldness have a distaste for fat ; 
and the ingestion of cod-liver and other nutritious oils, fat meat, or 
linseed aud linseed oils, as recommended by Sherwell, is for such 
patients advisable. Iron, strychnia, tar, phosphorus, and arsenic often 
meet the indications presented. 

A scanty crop of short, soft, downy hairs may, however, push for 
a time to the surface, but soon yield before the inactivity of the 
follicles in which they are implanted. Inasmuch, however, as excep- 

32 



498 



DISEASES OF THE SKIN. 



tionally brilliant results are occasionally obtained by treatment, the 
latter is always deserving of a trial. When the alopecia is symp- 
tomatic of some local disease of the scalp, the latter of course is first 
to be relieved by the measures appropriate for each, as, for example, 
the use of parasiticides in those of parasitic origin. The total or 
partial symmetrical losses of hair occurring in the course of systemic 
disorders have a much more hopeful prognosis. Exception, how- 
ever, is to be made of the tardy syphilitic alopecia associated with 
local scalp lesions or profound cachexia. In all forms of syphilitic 
alopecia, local as well as constitutional treatment is indicated. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap, or combinations of glycerin, alcohol, and sapo 
viridis to meet the requirements of individual cases. The scalp, 
after all such shampooings, should be anointed with lanoline, plain 
or salicylated ; vaseline ; the oil of benne ; or scented castor oil. In 
obstinate cases the nail-brush may be vigorously used over insensitive 
scalps at the time of the shampooing. The salve used may be often 
advantageously medicated with sulphur, chrysarobin, tar, cantharides, 
or mercury. Formulae for lotions and salves to be used in this way 
are appended : 



r£. Hydrarg. chlorid. corros. 

Spts. vin. rectif. 

Glycerin. 

Aq. ros. 
external use over the scalp. 




grs. v; 

fij; 

Ev; 


64 

16 

192 


33 

M. 


R . Picis liquid, [vel. ol. rusci] 
01. lavandul. 
01. pin. sylvestr. 


} 




4 

192 


M. 

[Piffard.] 


r* . Hydrarg. chlorid. mit. 
Hydrarg. ammon. chlor. 
Vaselin. 




ad^j; 


51 

266 
32] M. 
[Bronson.] 


R . 01. sabinse 

Spt. vin. rectif. 


gtt 


v-xxx ; 


133-2. 

32l M. 
[Pincus.] 


K . Hydrarg. bichlorid. 
Cantharid. tinct. 
Medull. bovis 
01. rosse 




gr. ss ; 

3ss; 

q. s. ; 


4 
16 

[Van Hi 


032 

M. 

irlingen.] 


Be . Acid, chrysophanic. 
Glycerin. 
Vaselin. 




gr. x ; 


66 
2 66 
28| M. 
[Anderson.] 


1£ . Sulphur, prsecip. 
Ungt. aq. ros. \ 
Vaselin. J 




3J; 

aa § ss ; 


4 
16 


M. 



Andre* is said to have induced an 
obstinate case of total baldness by 



abundant growth of hair in an 
hypodermatic injections of the 



ALOPECIA. 499 

muriate of pilocarpine, from one-eighth to one-fourth (0.008-0.016) 
of a grain being injected on each occasion. 

The treatment of alopecia is largely that also of alopecia fur- 
furacea ; aud alopecia areata. 

Alopecia Furfuracea, 
(Pityriasis Capitis ; Alopecia Pityrodes Capillitii.) 

Under this title is included that loss of hair, varying greatly in 
degree from moderate thinning of the growth to considerable sym- 
metrical baldness, usually of the vertex, which, at the onset, is 
scarcely distinguishable from alopecia simplex, alopecia prematura 
or presenilis, and seborrhoea of the scalp in some of its forms. It 
is exceedingly common, especially in men. 

The disorder, essentially chronic in course, is usually first mani- 
fested in early adult life, though persons of both sexes, from twelve 
to fifteen years of age, may at these ages display typical forms of the 
disease. After some months or years, the subject of the affection 
discovers a relatively large loss of hairs from the scalp, producing 
thinness of the growth upon the vertex, near the brow or over the 
temples. The hairs, when examined in situ upon the scalp, are 
shortened and rebellious to the comb and brush, projecting stiffly 
from the brushed surface, being also harsh, lustreless, and rarely well 
anointed with sebum. Those shed from the scalp, especially of men, 
are found to be nearer in type to the lanugo or downy hairs than 
those which fall physiologically from a vigorous growth of hair in, a 
healthy subject ; that is, they are short, thin, pointed, and often with 
an indistinct medulla. 

At the same time the scalp is in process of incessant desquama- 
tion, the scales being of pityriasic type, and exceedingly abundant 
so long as the alopecia is not complete, after which the epidermal 
catarrh promptly disappears. The mealy, bran-like scales are shed 
in a fine shower upon the clothing of the patient, and, the disease 
being more common in men than in women, its traces are often dis- 
tinct upon the collar of the coat after the fingers have been passed 
through the scalp. The same flour-like, whitish and grayish scales 
are distinct and plentiful among the hairs to which they cling, and 
also can be recognized over the scalp surface when the latter is 
inspected with care. Greasy conditions of this product of secretion 
upon the scalp are due to complications with a seborrhoea of this 
region, and the reader is urged to consult the chapter devoted to that 
malady in order to study this subject from its several pathological 
sides. According to Pincus, three-fifths by weight of the scales fur- 
nished by the scalp in this condition are inspissated products of 
sebaceous secretion. 

Often, however (and it is this important feature which justifies the 
separate consideration of alopecia furfuracea and seborrhoea capitis), 
the scales are true squamae ; dry, corneous, and epithelial, rather 
than fatty and seborrhoeic. The subjective sensations are then 



500 DISEASES OF THE SKIN. 

usually marked ; the scalp is often scratched and torn by the nails, 
and is, in some cases, reddened and thickened. There may be also 
decided general cachexia. Among women the patients are often 
nervous and sallow, with a long history of distressing headache, 
uterine hemorrhage, or hepatic disorder. These are simply states in 
which there is malnutrition of the scalp. 

The scalp may or may not be the seat of perspiration. Eczema, 
of pustular type occasionally complicates these cases. 

Etiology. — The disorder may be due to inheritance, to any systemic 
affection impairing the bodily vigor, to long-continued neglect of the 
hygiene of the scalp, or to such diseases of women as are accompanied 
by menstrual irregularities. The confinement necessitated by seden- 
tary occupations of life ; those trades and professions w T hich permit 
or require the constant covering of the head of men ; and the wearing 
of heavy hats or bonnets interfering with the aeration of the scalp, 
all furnish conditions for the occurrence of the disease. 

In 1882, Lassar and Bishop produced alopecia by rubbing upon 
the sound surface of the skin of animals the epidermic detritus and 
hairs furnished by a patient affected with the disease. This lends 
color to the possibilities of contagion, which should not be ignored. 

Pathology. — According to Boeck, Malassez, Balzer, and others, the 
cocci and bacteria recognized in the scales removed from the surface 
may be efficient causes of the disease; but Malassez shows con- 
clusively {Arch, de Physiol., 1874, p. 451) that the micro-organisms 
thus discovered may be in full activity and yet not exclusively 
responsible for the morbid state. According to the more modern 
view of the role of these germs in all the alopecias, they are regarded 
as harmful accessory agents, rather than as sole and efficient causes of 
the disorder. 

According to Pincus, the vessels of the scalp are unaltered, 
but the corium beneath the affected surface is thinned in proportion 
to the severity of the disease. Nothing characteristic can be discov- 
ered in the hairs removed from an affected patch. 

Diagnosis. — The disease is distinguished from seborrhoea of the 
scalp by the epithelial character of a great part of the dry discharge 
occurring symmetrically from the scalp surface, coupled with the 
symmetrical and largely vertical alopecia. The asymmetrical greasy 
patches of pure seborrhoea capitis, pasting the hairs to the scalp, 
which may be limited to the occipital or temporal region of one side, 
are strikingly different. Michelson and Pincus place reliance in 
establishing a diagnosis, upon the firmer attachment of the scalp and 
the discovery upon four successive days of a proportion of one-eighth 
of pointed hairs to the entire pilary loss, with an average length of 
thirteen centimetres. 

Treatment. — The general and local treatment of alopecia furfuracea 
is practically that of alopecia simplex, alopecia areata, and seborrhoea 
of the scalp. 

Pincus applies upon compresses the sodium bicarbonate in solution 
sufficiently concentrated to stimulate but not redden the non-hairy 



ALOPECIA AREATA. 501 

• 

portions of the skin. Sulphur, tannin, the oil of saviu, the bichloride 
of mercury, tar, naphthol, resorcin, the peroxide of hydrogen (in two 
volumes), and ichthyol have all been successfully employed in the 
management of these cases. Each is best preceded by the shampoo- 
ing described in the preceding chapter. Schmitz, Schiiller, and 
Andre have all reported excellent results from hypodermatic injec- 
tions twice weekly of one-twelfth to one-sixth of a grain (0.005- 
0.010) of the muriate of pilocarpine in distilled water. 

No remedy has a higher and more established value in the local 
management of these cases, whether in an early or late stage, than 
sulphur. In the strength of from one-half to one drachm (2.-4.) of 
precipitated sulphur to the ounce (32.) of vaseline or lanoline, it 
should be well-rubbed into the scalp after each shampooing. When 
there is marked improvement of the pityriasic catarrh, one of the 
stimulating lotions may be used that are, described in the pages 
devoted to the other varieties of alopecia. 



Alopecia Areata. 

Lat, area, a vacant space (arere, to wither, Fox). 

(Porrigo Decalvans ; Tinea Decalvans ; Area Celsi ; Area John- 
stoni ; Alopecia Circumscripta ; Fr., Pelade.) 

Statistical frequency in America : 0.749. 

Alopecia Areata is a disease of the pilary follicles characterized by the sudden 
occurrence of general and symmetrical, or partial and asymmetrical baldness, 
the latter exhibited in distinctly circumscribed, smooth, whitish patches, which 
are, in typical cases, completely destitute of hair. 

Two forms of this disease occur, that in which the baldness develops 
in patches ; and that in which there results either rapidly or slowly 
a generalized loss of hair. The latter may begin with display of 
circumscribed patches, or the loss of the pilary filaments may be 
almost from the first both general and symmetrical. By some authors 
these two varieties are regarded as separate affections. 

Symjitoms. — This disorder, which is more common than is gener- 
ally believed by physicians, may be, at its outset, preceded or accom- 
panied by symptoms of ill-health, such as headache, malaise, inappe- 
tence, loss of flesh, or malnutrition. In yet other cases, cephalalgia, 
parsesthesia, pruritus, and formication of the skin of the scalp and 
other regions, indicate some disturbance of the nervous centres. 

Often, however, the patients of this class are in sound health, the 
disease then manifesting itself by the sudden and complete loss of 
hair over a circumscribed patch, usually upon one side of the scalp, 
so rapidly effected that they often describe a first discovery of the 
fact at the toilet of the morning. After a variable period of time, 
other patches of baldness may occur, all of the hairy portions of the 
body being liable to the affection, the scalp first in order, next the 
beard, then the genitalia, axillae, brows, eyelids, and the general sur- 



502 DISEASES OF THE SKIN. 

face of the body. In early childhood cases occur in which the closest 
scrutiny with a glass fails to detect a single filament of hair upon any 
portion of the skin. 

The patches may be roundish, ovalish, or irregularly shaped, 
and vary greatly in size, from that of a small coin upward. They 
maybe so numerous as to disfigure the entire scalp ; and though 
these touch at the borders when thus numerous, they can scarcely 
be said to coalesce, as the individual elementary areas are usually 
recognizable. Their surface is smooth, whitish, and often per- 
fectly destitute of hairs ; it is rarely tumid, and slightly reddened. 
The hairs at the periphery are usually of full length and may be 
fixed in situ, but are occasionally fragile, and, as a rule, readily with- 
drawn from their follicles. Stumps of such friable and loosened 
hairs may be at times seen at the margin of the patch. In point of 
abnormal subjective sensations, temperature, or disease of the surface 
from which the hairs have fallen, there is, as a rule, complete absence 
of symptoms. The skin, when the evolution of the disease is com- 
plete, is usually normal to the touch, and pliable. Occasionally it is 
anaemic, thinned, and more movable over the pericranium than in 
the sclap which is not the seat of the disease. 

In incomplete evolution and in periods of repair, downy hairs may 
appear upon the surface, at times considerably differing in color from 
those springing from unaltered regions of the scalp. 

The loss of hair from the surface may be : rarely, gradual ; pre- 
ceded by mild pruritus (Besnier et Doyon) ; or followed by anaes- 
thesia (Neumann). Its apogee once attained, the course of the disease 
is variable ; it may persist for periods without apparent change ; or 
new patches may form while those of an older date either proceed to 
exhibit wholly or in part the pilary growth ; or, this latter accom- 
plished, suffer a fresh loss by relapse. Shifting areas of baldness 
may in this manner invade the entire surface of the scalp, which yet 
at any one moment of time exhibits a loss of but the half of its 
hirsute covering. 

The variations exhibited by the disease in its evolution are numer- 
ous but rarely mask its special features. The hairy loss is usually 
first apparent on the scalp ; but may be first conspicuous over the 
region of the beard in the male subject. Though the larger sized 
patches formed by coalescence of several of the smaller may form 
with relative rapidity, once fully developed the condition may remain 
for weeks and even months apparently unchanged. At the periph- 
ery, the hairy filaments may be short, straight, very loose, and exhibit 
at the bulb a spade-like extremity, or an attenuated point, the non- 
atrophied shaft thus contrasting with the wasted portion implanted 
below the cutaneous level ; or, especially when repair is about to set 
in, the hairs at the border of the patch may be firmly fastened in 
situ. When the filaments begin to reappear over the bald patches, 
there is commonly a fine downy growth over the affected area, later 
replaced with a crop of thicker and stronger whitish filaments, these 
last always replaced, in cases terminating favorably, by a growth of 



ALOPECIA AREATA. 503 

hairs as well colored, as vigorous, and as persistent as any which 
which were at first lost. An odd appearance is often presented by 
patients who are improving, when the strong and white new hairs 
contrast vividly in color with the dark shade of those on the unaf- 
fected scalp. 

When the disorder becomes universal the result may be rapid or 
very slow, and this either after persistence (or the reverse) of the dis- 
ease in patches. This variety (or complication) of alopecia is fortu- 
nately rare and usually occurs, if at all, after the middle period of 
life, but it may develop in the very young. 

Variations occur also in the appearance of the patch. Usually it 
is compared in appearauce with the whiteness and smoothness of a 
billiard-ball. At times, for a brief while, it is seen covered with 
stumps of friable and fallen hairs. Again, hairs are left which the 
French describe as " cadaverized," dead, and merely retained in place 
by mechanical adherence. In yet other cases, the surface is tumid, 
reddened, and even hypersetnic. It is not very rare to discover 
alopecia areata in patches which are also the seat of the vegetable 
parasites. I have had under observation a gentleman, long psoriasic, 
exhibiting a typical seborrhoea capitis and later developing a no less 
typical alopecia areata. 

The course of the disease in young subjects is usually toward a 
favorable result. There is hope, as a rule, when even the downiest 
and thinnest growth, requiring a good light and even a glass for its 
recognition, can be appreciated. Even when so feebly attached that 
these filaments are removed with ease by the fingers or brush, and 
even when they spontaneously fall, they may be replaced by crop 
succeeding crop of stronger filaments, which eventually persist. In 
all serious cases, usually after the forty-fifth year of life, there is 
absolute atrophy of the hair follicles and a resulting remediless 
baldness. 

There is some reason for believing that the disease has a relatively 
fixed period of evolution, though the exact limits of the latter are not 
known. Few individuals suffer less than one year ; the most are 
relieved within a period of two years. These remarks, however, 
apply to the asymmetrical forms of the desease in the relatively 
young. The symmetrical alopecia areata of the middle-aged is, in 
my experience, a far more formidable affection. 

Few diseases are the source of greater mental distress than those 
of the class now under consideration. The prominent deformity 
thus occasioned debars the subject of the malady from social relations 
of many kinds, and this intensifies the morbid feeling which every 
reflected view of the head awakens. This is particularly true of 
women. The successful management of these cases calls often for the 
supporting assurances of the practitioner. 

Etiology. — The question of the parasitic or neuropathic origin of 
alopecia areata is still undecided, though it has been the subject of 
extended discussion and observation. The most reasonable explana- 
tion of the differences to be here noted lies in the fact that patches of 



504 DISEASES OF THE SKIN. 

baldness upon the scalp and elsewhere, leaving the surface destitute 
of hairs and otherwise not apparently affected, may result from 
widely differing causes. Something of this sort is assuredly the result 
of early syphilis ; and a study of the pages which follow will suggest 
that it is more than probable that in other different affections the 
result may be similar. 

Eichhorst, Thin, v. Sehlen, 1 Robinson, 2 and others have discovered 
in alopecia areata micro-organisms in affected patches and about the 
bulbs of hairs, which have even been cultivated in generations but 
which have not yet been shown to be effective in the production of 
the disease oh novo. Yet, as if to demonstrate the efficacy of some 
such agency, not a few outbreaks of the disease have been reported 
both in France and America, where entire companies of a regiment, 
or numbers of inmates of public institutions have suffered from the 
disease in an apparently contagious form. It is, however, noticeable, 
as Besnier and Doyon have shown, that in these instances, neither 
the hairs themselves nor their sheaths exhibit any of the changes 
commonly recognized as the result of parasitic invasion, in the way 
of splitting, Assuring, peeling of cuticle, or irritation. There is in 
all, but one picture, it is that termed by the French " cadaver ization." 
The hair-bulb is simply desiccated, shrivelled, and wasted. 

On the other hand, the weight of evidence in favor of a neuro- 
pathic origin of some cases of the disorder is great and very generally 
accepted by authorities. Mental emotion (anxiety, fright), anaemia, 
innutrition, traumatism both general and local (falls upon the head, 
blows inflicting lacerated wounds of the scalp), and bodily injuries 
of the general surface, have all been cited as effective. 

It occurs with equal proportion in the two sexes ; and among 
these, irrespective of social condition. Of the partial and asym- 
metrical forms, the larger number of cases occur in young subjects, 
from childhood to early adult life. The severe and generalized forms 
are more often encountered in middle-aged persons. In the latter 
class especially, it is occasionally observed to follow the obscure dis- 
orders of the nervous centres due to sudden or prolonged undue 
excitation. In young subjects one may often discover a peculiar 
repugnance to the ingestion of fat and meat, a point to which atten- 
tion is called in considering alopecia simplex. 

The neurotic explanation of this disorder is more generally 
accepted as facts accumulate bearing on its etiology. The nervous 
symptoms which often precede or accompany the appearance of the 
bald patches are strikingly suggestive, and led Von Barensprung to 
announce his theory of " inherited innervation " as a cause of the 
malady. Further, the occurrence of the disease after shock of the 
nervous centres is significant. Max Joseph has produced baldness 
in patches upon the ears of cats and rabbits by section of the second 
cervical nerve near the inter-vertebral ganglion. 

1 Annal. de Derm, et de Syph., June, 1886. 

2 Monatschft. f. prakt. Dermat, 1889, vii. p. 409. 



ALOPECIA AREATA. 505 

Collier 1 cites two eases in which alopecia areata followed a blow 
upon the temporal region, and Sir Dyce Duckworth reports the case 
of a gentleman who sustained an injury to the head in a fall from a 
dog-cart, who suffered as a result from permanent loss of hair. 
Overal 2 has reported a similar instance. 

Pathology. — The anatomical lesions which produce alopecia areata 
have not been recognized. The hairs fallen from the surface, when 
examined with the microscope, are seen to be atrophied in the bulb 
and shaft, though Rindfleisch describes in certain cases a node-like 
enlargement of the hair-shaft after its escape from the follicle. 
Fracture of the shaft is in some cases also noted, evidently an acci- 
dent of the process. A large number of micro-organisms besides 
those observed by the authors cited above, and by Feullad (Teignes 
and Teigneux, Paris, 1886), Schiitz (Monat. f.prakt. Derm., 1887), 
and Plattner (Inaug. Diss. Chirur., 1890), can be recognized upon 
the surface and about the hair bulbs. I have in several cases detected 
spores and mycelia of the trichophyton in the hairs, a coincidence of 
disorders w T hich has been observed by others. 

In default of more positive knowledge on the subject, many der- 
matologists have assumed the disease to be a trophoneurosis, a view 
sustained by the etiological history of certain cases. 

Michelson, however, regards the vasomotor nerves as presiding 
over the nutritive changes determining the loss of hairs. Schultze 
recognized some thinning of the scalp in sections examined by him. 
Future investigation may establish some difference other than that of 
degree between the partial asymmetrical disease of the young and the 
more general symmetrical affection of middle life, in which the entire 
scalp, lids, brows, pubes, and axillae are completely shorn of their 
filaments. 

Diagnosis, — Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments, moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm and favus of the scalp, the disease in question is 
readily differentiated, by the suddenness of its onset ; the absence of 
stumps of hairs, scales, crusts, and evidences of irritation in the 
involved area ; the whiteness, smoothness, and complete baldness of 
the latter ; and, above all, by the failure to detect with the micro- 
scope the evidence of the presence of a vegetable parasite. 

The asymmetrical patches of seborrhcea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the surface, as 
well as by the slow and very gradual onset of the disorder. 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those re- 
sulting from traumatic injuries of the scalp, with cicatricial results, 
are easily determined as having such an origin. 

1 Lancet. Amer. Ed., August, 1881, p. 130. 

2 Alien, and Neurol., St. Louis, 1886. 



506 DISEASES OF THE SKIN. 

Treatment. — One must necessarily view with some distrust all 
treatment for that disease which in the course of months or years 
usually terminates in spontaneous recovery, and in the meantime 
may bid defiance to each and every therapeutic measure. Neverthe- 
less, persistent and hopeful management of even the apparently 
desperate cases is occasionally rewarded by such brilliant conse- 
quences that, however slight may be the foundation for a belief in 
the value of the therapy employed, it deserves recognition and trial. 

The hygienic management of every case is a matter of great 
importance. Tobacco should in every form be denied to subjects 
of the disease addicted to its use. Iron, quinine, nux vomica, cod- 
liver oil, phosphorus and the hypophosphites, arsenic, and strychnia 
are often indicated, and used with great benefit. 

The general condition of the patient affected with this disease is 
always to be considered. Where ferruginous and other tonics are 
indicated, the general tone of the nervous system is always to be 
considered. There are few patients who do not require daily salt- 
and-water bathing of the entire bodily surface, followed by brisk 
friction, especially over the spinal region. In the case of children 
this must be practiced by a skilled hand. When practicable the 
cold douche is even to be preferred. 

The indication for local treatment is to destroy any parasites that 
may be present and increase the physiological afflux of blood to the 
hair-follicles. With this end in view, the affected parts are to be 
bathed daily in water as hot as can be tolerated, then dried, and 
scrubbed with a stimulating lotion. The articles usually employed 
are alcohol, ether, turpentine, ammonia, camphor, cantharides, 
carbolic acid, oil of mace, croton oil, tincture of nux vomica, tincture 
of capsicum, tincture of aconite, castor oil, tar, iodine, sulphur, and 
the mercurials. All frequently fail. Several of these in combina- 
tion seem at times to be of service. 

The following is a formula, the ingredients of which may be 
varied to suit the indications in different cases : 



M. 



01. ricini 


fgss; 


16 


Acid, carbolic. 


3J; 


4 


Cantharid. tinct. 


,^ss; 


16 


01. rosmarin. 


gtt. xv ; 


ll 


Spts. vin. rectif. 


ad f.^iv; 


128 1 



Sig. For external use over the scalp with friction. 



The formula? containing chrysophanic acid and the bichloride of 
mercury, given on a preceding page in connection with the treatment 
of alopecia furfuracea, are often valuable. 

Dr. Nevins, of Liverpool, mops the entire surface with strong 
liquor ammoniae. Speedy return of hair in a patch of alopecia 
areata has followed a single application of pure creasote to the 
surface, resulting in moderate vesication. The spirit of turpentine 
and pure carbolic and acetic acids have been similarly employed ; but 
all these caustic applications are to be used with excessive caution. 

By many experts epilation is carefully practiced, so as to produce 



ALOPECIA AREATA. 507 

a zone of baldness about each patch, to the extent of removing all 
the loosened hairs at the periphery. By others, having in mind the 
parasitic origin of certain cases, shaving of such borders is substituted 
for epilation. By these also the remedies selected for application are 
of the order of the parasiticides, e. g., the mercurials, sulphur and its 
compounds, chrysarobin, pyrogallol, and iodine. 

Repeated blisterings of the scalp with cantharidal collodion, the 
spirit of green soap, and petroleum have also been employed exter- 
nally with success. The ointment of chrysarobin has the disadvantage 
of staining not only the remaining hairs, but often the face in conse- 
quence of the frequency of its transmission to that locality by the 
medium of the hands. When patients, however, consent to its use, 
it is worthy of a trial, as its application has been speedily followed 
by a vigorous growth of new pilary filaments. Andre employed ten 
hypodermatic injections of muriate of pilocarpine in one-eighth grain 
(0.008) doses, which resulted, in the case of a middle-aged woman 
affected with total symmetrical baldness, in an abundant growth of 
hair. The bichloride of mercury has been similarly employed. 

Lassar and Bishop 1 operated by first vigorously shampooing the 
entire scalp daily with a strong solution of tar soap for fifteen 
minutes ; rinsing next with an irrigator, by the aid of warm water, 
followed by cold water, and subsequently drying. Then a corrosive 
sublimate wash (1. : 300. adde spts. cologniens., glycerin., aa 100) 
was applied, and the head again dried ; then a solution of naphthol 
(naphthol, 0.5 ; spts. dil., 70. ; aq. dest., 30.) was rubbed in. 
Lastly, carbolized oil, 1 J per cent., was poured slowly over the scalp, 
entering the cleansed aud expanded orifices of the glands, so that 
seven drachms (28.) could be employed at a time. This was pursued 
daily for eight weeks. 

Faradization of the scalp with a stiff wire brush, pushed to the 
point of producing moderate hyperemia, has been followed by excel- 
lent results. 

Wilson recommends : 

R . 01. amygd. dulc. f ^j ; 32 

Capsici tinct. f 3 ij ; 8 

Liq. ammon. fort. f ^ j ; 32 

Spts. rosmarin. fjfv; 160 

01. limon. f 3J ; 4 



M. 



Here is another stimulating application : 

M. 01. terebinth. 1 --c-z 1C 

r\i • • • > aat x ss ; lb 
Ol. ncmi J ° ' 

Origani tinct. f £j ; 4 

Ol. camphorat. f %] ; 32 

Liniment, volatil. adf.^iij; 96 

Sig. For external use with a brush till the scalp is irritated. 



M. 



Prognosis. — From what precedes, it will be justly inferred that, as 
regards the relief of the baldness, the asymmetrical development of 
patches in youth is much more favorable than the symmetrical gen- 



Loc. cit. 



508 DISEASES OF THE SKIN. 

eral disease of middle life, the latter being often remediless. The 
prognosis of the same affection of the beard is quite favorable. In 
all cases, the practitioner should actively persevere to the end. In 
no case should any encouragement be given as to complete relief 
within the year, though such exceptionally short careers of the dis- 
ease are at times observed. 

The disease, when limited to the regions of the beard in young 
men, usually concludes its stadium in the course of about one year, 
with a favorable termination. Shaving should be regularly prac- 
tised, as the deformity is thus rendered somewhat less conspicuous, 
and the bald surface should be frequently stimulated with one or 
several of the topical applications named above. Alcoholic solutions 
of the mercuric bichloride, half to one grain (0.033-0.066) to the 
ounce (32.) are to be well rubbed over the patch or patches once or 
twice daily. The disease in this locality may coexist with benig- 
nant syphilis, the latter disease pursuing a career considerably 
shortened by vigorous treatment, while the former, none the less, 
endures from twelve to fourteen months, long after the syphilitic 
cachexia has been relieved. At the end of this time, recovery occurs 
precisely as in those cases which have presented no history of in- 
fection. 

In all cases of implication of the head, where the scalp is involved 
in either sex, and where the peculiar hypochondriasis of the disease 
is developed, a wig should be worn for the sake of its moral effect 
upon the sufferer. For such, however, its use should be limited to 
social occasions, visits, etc., as the persistent wearing of a perruque 
indoors seems to lengthen somewhat the course of the disease. 

Alopecia Neurotica. — Under this title Michelson includes all 
cases of loss of hair, (1) coincident with or following traumatism of 
cerebral or peripheral nerves ; (2) those associated with diseases of 
the nervous system due to internal causes. As to the first class, 
instances of alopecia are given above, where, as in the case reported 
by Sir Dyce Duckworth, the loss followed a fall upon the head. 
Todd, Schultze, Fischer, and Michelson have also made observations 
of this character. In the second category are the local and general 
losses of hair reported as associated with melancholia, migraine, 
neuralgias of persistent type, and facial and other paralyses. In 
some of them the skin and panniculus adiposus have wasted, the 
hairs falling in stripes or ribbon-shaped streaks, with partial or 
complete canities of those left in the follicles. 



Alopecia Follicularis. 

(Folliculites et Perifolliculites destructives du follicule pileux ; 
Folliculites et Perifolliculites decalvantes.) 

A series of differing morbid processes may involve the hairy folli- 
cle and its adjacent parts with the result of destroying not merely 



ALOPECIA FOLLICULARIS. 509 

the hair bulb, but also the reproductive power of the hair-sac. As 
a result there is an alopecia, either limited to a single hair-pouch or 
with multiple involvement and a loss of individual hairs here and 
there over a considerable area ; or even a loss of pilar y filaments in 
groups where the baldness may result in a somewhat conspicuous 
deformity. These disorders, studied with special care by French 
observers, are yet but imperfectly understood, and none is perfectly 
distinguished from the other dermatoses resulting in hair loss. 

They are usually divided in a first class with disseminate; and in 
a second with grouped lesions. 

In the first, are included all affections of the hairy region of the 
body capable of producing suppuration and destruction of the hair- 
follicle. Here, as in the second class, are effective many of the 
micro-organisms which invade the other anatomical portions of the 
skin. In the order of importance in this connection are to be named 
the staphylococci and the microbes of syphilis, variola, and lepra. 
I am well convinced that in both classes there are lesions due to 
infection with tubercle bacilli whose characteristic features will be 
one day fully recognized. 

In the second class are collected a number of disorders briefly named 
below where the lesions are aggregated in patches. They are all 
characterized by an inflammatory change in the follicles and peri- 
follicular tissue, followed by destruction of the hair papilla, a result- 
ing remediless alopecia, and the formation of cicatriform tissue as a 
substitute for the normal skin originally provided with follicles and 
hairs. Brocq includes in this class the disorders named below, many 
of them of great rarity ; some observed by but a few experts. 

(a) Cicatricial alopecias in small irregularly disseminated plaques. 
These can be recognized when any scalp which has been the seat of 
a severe alopecia pityrodes is minutely studied. They are probably 
accidental results of that morbid condition and due to infection of 
the follicles with cocci. 

(6) Cicatricial alopecias of the scalp, eye-brows, and face, where 
minute glistening whitish points result, compared by Brocq to the 
lesions produced by the destruction of the hair papilla in electrolysis. 
It is possible that these are due to the cause suggested for the group (a). 

(c) False alopecia areata ( u pseudo-pelade," of French writers). 
In these cases the scalp about one or several hair follicles becomes 
tumid and reddened. The hair is loosened in its pouch, and whether 
it fall spontaneously or be removed by epilation, it is not replaced 
by another. The scalp is left whitish, smooth, ivory-like, depressed, 
thinned, and apparently atrophied, without trace of new-formed 
downy hairs so often noticed in alopecia areata. As distinguished 
from the last named disorder, the advance of the patch may be in 
irregular lines rather than by extension of the rounded or oval circles 
formed in alopecia areata. Minute islets of alopecia exhibit the out- 
lying evidences of disease. 

(d) Cicatricial alopecias with a punctiform appearance of the 
plaque. Here there is an inflammatory involvement of the follicle 



510 DISEASES OF THE SKIN. 

and peri-follicular tissue, with redness of this special region disap- 
pearing after atrophy has occurred. The sequel is depressed whitish 
cicatriform tissue, marked here and there with pin-head sized, reddish 
points where the circumpilary exudation is still in activity. 

(e) Quinquaud's Disease. 1 (Acne Decalvante, of Pailler and 
Robert). Here miliary abscesses, punctiform, pin-head sized, and 
larger, involve the follicle. The hair, originally piercing these sup- 
purative lesions, is loosened and falls, after which the follicle atro- 
phies and the hair is no longer produced. The scalp is left dead- 
white, thinned, depressed, atrophied, and cicatriform, in patches as 
large as those visible in alopecia areata, but often irregular in outline. 
The follicles remain distinct and are not fused in a mass ; they re- 
semble the distribution of the lesions in coccogeuous sycosis. With 
the micrococcus recognized in the cases under his observation and 
cultivated, the author has induced similar disease of the follicles with 
loss of hair. In some instances this special follicular alopecia has 
progressed without suppurative involvement of the follicle over the 
hairy surface. 

(/) Lupoid sycosis (Brocq). Special attention should be directed 
to this affection, as it is of great importance to distinguish it from 
the more common variety of coccogenous sycosis, which it strongly 
resembles. I have studied three typical cases of this rare malady ; 
and, though not yet in position to assert it with positiveness, I 
believe it will be shown to be one of the forms of cutaneous tuber- 
culosis. 

The disease affects chiefly the male beard (region more accessible 
than the scalp to the fingers charged with tubercle bacilli), and its 
early symptoms are well nigh indistinguishable from those of sycosis 
of the type named above. There are large and small, well-defined, 
follicular and peri-follicular pustules, with redness, infiltration of the 
derma, scales, crusts, and characteristic deformity. But as the dis- 
ease progresses, the hairs are removed from the whole or a large part 
of the involved area, and there is left, after a relatively long period, 
occasionally suddenly produced, a cicatricial or keloid-like surface, 
which may be smooth or highly irregular. 

In mild cases, there is left a reticulum of narrow, scar-like, whitish 
lines, irregularly radiating over the surface, giving to the eye and 
touch the suggestion that they are depressed below the general level 
of equally irregular areas of the bearded chin or cheek. These 
areas may or may not be provided with hairs. In the former event 
the growth is stunted by the contracture of the encircling atrophy, 
where a species of fibrosis has occurred. 

In severer cases there is left a more generalized cicatriform tissue, 
for the most part unprovided with hairy filaments. The process 
may be so severe as to interfere, not seriously, but to a degree, with 
the movements of the lips in articulation and mastication. The 
parts for months after the disease has accomplished its involution are 

i Bullet, de la Soc. Med. des Hopit., 1888. 



ATROPHIA PILORUM PROPRIA. 511 

still somewhat reddened. In both forms the centrifugal direction of 
the morbid process has been observed. 

(g) In a last group are placed a few ill-defined cicatricial alopecias, 
beginning often with peri-follicular, rather than follicular, pustula- 
tion, accompanied by redness of the affected part and the eventual 
formation of peculiarly persistent crusts. When these fall, a reddish, 
slightly scaly surface is left, followed by cicatricial atrophy and a 
patch with distorted and friable or fairly vigorous hairs, surrounded 
by an elevated rim. There is little definition ; distinct patches of 
the disease are rarely seen. It more often affects the beard, and may 
be symmetrical. It may coexist in the same subject with acne-keloid, 
atrophic acne, and other varieties of that disorder, with which it is 
unquestionably related. 

It w 7 ill be seen from the foregoing that a series of interesting and 
important affections of the hairy parts has been recognized, as yet 
not distinctly differentiated each from the other and the series from 
all others. Some of them may be eventually found to be varieties 
of lupus erythematosus of the scalp. Kaposi's dermatitis papillaris 
capillitii is without question to be recognized in some of the descrip- 
tions given. A few may be rare localized gummatous changes pro- 
duced by syphilis. All are best treated with corrosive sublimate 
lotions, one part to four hundred ; boric acid lotions and powders ; 
and salves containing mercury, sulphur, and iodine. Galvano- 
cauterization of the pustules and inflammatory points has been suc- 
cessfully employed in some of the reported cases. All are well 
managed if treated in accordance with the principles suggested in 
the chapter on Sycosis. 

Atrophia Pilorum Propria. 

Atrophy of the hair may be either symptomatic or idiopathic. 
Illustrations of the first-named condition are observed in phthisis, 
syphilis, seborrhcea, ringworm of the scalp, and almost all general 
diseases interfering with the nutrition of the pilary growth. The 
filaments then become dry, lustreless, friable in both longitudinal 
and transverse diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the 
hair. One of these exists in those long hairs which are seen to be 
irregularly thinned or flattened in the shaft, and split at the point 
into two or more recurving fibrillse, a condition noted, for the most 
part, in few hairs scattered among those of full development and 
vigor. This especially localized atrophy seems to be peculiar to one 
or more follicles merely; and is quite analogous to the condition in 
which there appears among the vigorous pigmented hairs of early 
life, a single blanched filament. 

Fragilitas Crinium. — Under this title a number of odd disor- 
ders, due to atrophy, and producing fragility, splitting, or curling in 



512 DISEASES OF THE SKIN. 

abnormal directions of pilary filaments, has been described by 
authors. 

The " Undescribed Form of Atrophy of the Hair of the Beard " 
of Duhring 1 is that in which either at the bulb or at a variable dis- 
tance from it, but within the follicle, there is fission of the hair fila- 
ment into from two to four stalks with coincident atrophy of the 
bulb itself, and consequent irritation of the surface. Duhring ? s 
patient exhibited to a marked degree the species of hypochondriasis 
to which the subjects of disease of the hair seem specially prone. 
Through the kindness of Dr. Duhring, the author has had the 
opportunity of privately examining under the microscope some 
specimens of these hairs, the appearances of which are admirably 
portrayed in the woodcut which illustrates his paper. This disorder 
is not induced by a parasite. 

In the year 1887, a gentleman applied to me for advice who was 
in a fair condition of general health, but the hairs of whose beard, 
when closely examined, both with the naked eye and the microscope, 
presented a striking resemblance to those described and figured by 
Duhring. Microphotographs of specimens of these hairs show 
clearly that in every case the fission of the filament extended com- 
pletely to the base of the follicle and produced local irritation there. 
The hairs over several square inches of surface were thus uniformly 
affected, normal filaments being in such areas absent. The inter- 
follicular spaces, however, seemed to be abnormally widened, as 
though in these areas such normal hairs might have fallen in con- 
sequence of a species of alopecia. The peculiar appearance of the 
beard to the naked eye was striking. The disease was much more 
strongly marked on the chin than on the cheeks or upper lip. The 
curling of some of the splinters was complete and characteristic. 

Trichorrhexis Nodosa 
(Trichoptilosis, of Devergie ; Nodositas Crinium), 

first described by Wilks and Beigel, is a condition in which the 
hairs display nodose swellings along the shaft at irregular distances, 
the beard and moustache being most often affected, though rarely 
there is involvement also of the hairs of the scalp, axillae, and pubes. 
Sherwell, 2 in this country, has described one such case. The hairs are 
brittle ; and fracture usually occurs through the node, leaving a 
broom-like mass of filaments projecting there, while the internodular 
portions of the shaft appear normal save for some enlargement of the 
medulla. The fragility of the hair at the centre of the node seems 
to depend upon the tension and consequent fissure of the cortical 
layer, which is greatest at that point. No parasite has been discov- 
ered in hairs thus affected, their bulbs, moreover, being firmly 
adherent in their follicles. Little is known as regards appropriate 
treatment of the disease, which is, it must be said, persistent and 

i Amer. Journ. of the Med. Sci , July, 1878. 2 Arch, of Derm.. July, 1879. 



ATROPHIA PILORUM PROPRIA 



513 



Fig. 60. 



disfiguring. Shaving has been followed in some of Kaposi's cases by 
good results ; while Roeser 1 advocates the local employment of dilate 
tincture of cantharides. 

Monilethrix (Ringelhaaren ; Moniliform, Beaded Hairs; Pili 
Annulati ; Aplasie Moniliforme Intermittente) is a somewhat rare 
condition first observed by 
Smith, as described below, 
and since by numbers of 
others, including Luce, 
Anderson, Crocker, Lesser, 
and Behrend. Like the 
forms of fragility described 
above, the hairs are pecu- 
liar in exhibiting along the 
shaft a succession of rings 
or nodes, between which 
are narrower portions of 
the shaft, of a color lighter 
than the pigmented nodu- 
lar or annular portions. 
The result is a character- 
istic checkered appearance 
in the hairs. Fracture 
always occurs in the inter- 
nodular part, the fractured 
extremity having a charac- 
teristic brush-like appear 
ance. These conditions are 
evidently due to atrophic 
changes in the internodu- 
lar parts ; with better de- 
velopment in the pigmented 
and thicker portions of the 
shaft, the whole due to nu- 
tritional changes in the 
hair papilla. Virchow ex- 
plains this condition as due 
to a periodic aplasia of the 
hair papilla. The obvious 
symptoms are clearly the 
results of a profound pro- 
cess, originating probably 
in the trophic nerves. 

Smith, 2 of Dublin, has re- 
ported a Case of Nodose 
Swellings of the shafts 
of the hairs. Through the 

i Annal. de Derm, et de Syph., 1877- 




Trichorrhexis nodosa. (After Schwimmer.) 



18, pp. 185, et seq. 
33 



2 Brit. Med. Journ., May 1, 1880. 



514 DISEASES OF THE SKIN. 

kindness of Dr. Duhring, the author was enabled to examine some 
of these hairs, micro-photographs of which were, at his suggestion, 
taken by Dr. Belfield, of Chicago. Here there was no fragility at the 
nodes, which commencing near the scalp were quite regularly dis- 
played along the shaft, the fracture being always internodular. The 
spherical swellings along the shaft were also pigmented in a brown 
hue, and these contrasting with the non-pigmented color of the unaf- 
fected portions of the shaft, gave the hairs a singularly " checkered " 
appearance. No parasite was discernible in any of the specimens. 

Michelson, under the title ." Expansions and Fissures of the 
Hairs," discusses together these and other abnormalities of the pilary 
system and concludes as to the most of them, that they are not 
separate diseases but expressions of an abnormal dryness and brittle- 
ness of the hair due to atrophy. Cases of broom-like Assuring and 
division of the shaft into larger longitudinal splinters, he regards as 
equivalent processes, both beginning by a cuticular loss and often 
merging into each other. 

This view may be sound with regard to a number of these rare 
affections ; but even a superficial examination of the longitudinal 
splinters shown in Duhring's and my cases, reveals the fact that the 
shaft represented by the sum of all its splinters, is greater than that 
of the average hair in diameter and circumference. Even the naked 
eye can recognize this fact. The epilating forceps seizing a single 
hair in the case of the author's patient was distended as in the grasp- 
ing of as many sound filaments as are represented by splinters. 

The therapy of these cases is not well determined. Michelson 
believes shaving to be useless and recommends systematic shampoo- 
ing and oiling — the process pursued in the cases treated by the 
author. Arsenic internally is worth trying in all cases where it is 
not contraindicated. 



Concretions Jpon the Hair-Shafts. 
Lepothrix. 

Gr., leirig, scale, and dpi!-, the hair. 

(Trichomycosis Nodosa.) 

This disorder, first described by Paxton in 1869, and since recog- 
nized by Patteson, Pick, Babes, Barthelemy, and others, is one affect- 
ing the hairs, chiefly of the axillae and genital regions. The filaments 
are dry, brittle, roughened, and loosened in their follicles. Under 
the microscope the shaft is seen to be for a great part or the entire 
length ensheathed in a concretion which may be here and there inter- 
rupted by furrows, a diffuse form of the affection. In a nodose form 
there are irregularly placed roundish masses, isolated from each other, 
and more numerous toward the point than near the implanted ex- 
tremity of the shaft. Crocker describes also circular and well- 
defined masses lying upon but not surrounding the shaft, three times 



beigel's disease. 515 

the diameter of the latter, and containing fibres of the cortex which 
have been split away by the concretion. The fracture may be clean 
or brush-shaped. The nodular masses are exceedingly well attached to 
the shaft, reddish, brown to blackish in shade. At times the reddish 
sweat of the axillae, due to micrococci, has been a coincident symptom. 

The nodes are found to be made up of chains of roundish or ellip- 
tical micrococci, which penetrate the cortical layers of the hair with 
ease in regions of considerable moisture and sweat. The micro- 
organisms at first obtain access by minute separations of the cuticle of 
the hair, and eventually penetrate more deeply, breaking up the corti- 
cal portions. While thus multiplying, an homogeneous substance, simi- 
lar to the chitine by which the louse fastens its eggs to the hair, forms 
the bulk of the concretion in which the colonies of cocci are lodged. 

The treatment is by shaving and external applications of the 
bichloride of mercury, 1 : 2000. 

Piedra, 

(Trichomycosis Nodosa,) 

is a term descriptive of blackish and exceedingly firm nodes, partially 
or completely surrounding the hairs, and distributed without special 
order along any part of the shaft. The nodes are of the size of pin- 
heads, and though occurring chiefly in the hairs of the head of women, 
have been seen also on the scalp and beard of men. Desenne, Morris, 
Juhel-Eenoy, and Lion have reported on these cases. The disease 
belongs to the group of hyphogenous disorders. The nodes are seen 
to consist of masses of spores with abundant mycelium, readily culti- 
vated, but never penetrating to the interior of the hair. The hair 
bulb remains intact, and the disease is at once relieved by shaving or 
cutting the affected filaments. It occurs chiefly in Cauca, Colombia, 
but has been recognized elsewhere. In a single case, that of a young 
girl sent me from the Eye and Ear Infirmary, there were numerous 
jet-black, horny, and dense spherical masses attached to the hairs of 
the eyelashes of each lid of both eyes. 

Beigel's Disease. 

(Chignon Fungus.) 

This is discovered upon artificial hairs, which exhibit on the shaft, 
dirty-brownish nodes, due to masses of parasites. The fungus has not 
been definitely distinguished. The nodes are irregularly strung along 
the shaft of the hair. 



516 DISEASES OF THE SKIN 



3. Of Nail. 

Atrophia Unguis. 

(Onychatrophia) 

Atrophy of the nails may be a congenital or acquired condition, in 
which there is deficient or defective production of the nail substance. 
The congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the pilary 
growth. The nails may be entirely absent in these cases, or merely 
tardy of evolution ; occasionally they are seen, especially upon rudi- 
mentary or coalesced digits, in defective and distorted shapes. 

In acquired atrophy, the nail may be changed either in color, bulk, 
elasticity, firmness, shape, or position. Thus the nail may be ex- 
panded and thin, narrow and acuminate, friable, furrowed, laminated, 
ridged, or otherwise distorted. It may be uniformly or partially 
lustreless, or singularly striped, or even speckled irregularly. 

These changes in various combinations result from traumatism 
chiefly, such injuries, for example, as are common to the toes in the 
boot or shoe, and to the fingers when actively employed in the trades. 
Excessive heat and cold, and constant maceration in chemical solutions 
(as among photographers, dyers, and druggists) often operate injuri- 
ously upon the nail tissue. All serious disturbances of systemic nutri- 
tion, such as are incident to prolonged fevers, surgical accidents, tuber- 
culosis, ataxic conditions, etc., interfere visibly with the nutrition and 
development of the nail. The syphilitic changes in the nail are com- 
monly due to gummatous involvement of the matrix. Severe ulcera- 
tion of the matrix is often followed by atrophic or other distorted 
conditions of the nail-substance. 

The treatment of these conditions is largely that of the disorders 
upon which they depend. The nails may often with advantage be 
soaked in unguents, scraped to a desired smoothness, well trimmed, 
and then protected by wax, leather stalls, etc., from injurious con- 
tacts. Arsenic internally is said to be useful in some affections of 
this kind. 

Achromia Unguium, 

(Albugo; " White Spots f Decolorization des Ongles,) 

is a peculiar condition found in young and healthy subjects who 
exhibit a number of dead white macules on one or several of 
the nails, usually of the fingers. Morison, of Baltimore, reported 
an interesting case to the American Dermatological Association 
{Viert.fur Derm. u. Syph., vol. xv., 1888), illustrated with a por- 
trait, in which linear striae, transverse to the long axis of the digit, 
appeared on the fingers. I have since then observed three similar 



ATROPHIA SENILIS. 517 

cases, one the subject of a portrait in oil, where this condition 
existed. In all of my patients, young people of each sex, the fin- 
gers were capriciously selected for exhibition of the peculiarity on 
the two hands. It has been supposed that the presence of air in the 
nail-substance is responsible for the appearance. I believe it to be 
a trophoneurosis, and due to nutritional changes in the nail matrix. 



4. Of Cutis. 
Atrophia Cutis. 

Gr., a, privitive ; and rpop), nutrition. 

Atrophy of the skin is an idiopathic or symptomatic, diffuse or partial, diminu- 
tion of the mass of the integument, or its reduction in size after loss or degen- 
eration of one or more of its histological elements. 

The skin and its appendages, in common with other organs of the 
body, may suffer from atrophy, either idiopathic or symptomatic in 
character, and general or partial in extent. It may result from either 
quantitative or qualitative, retrogressive changes, losing thus its nor- 
mal dimensions, either from wasting of one or all of its normal ele- 
ments, or from degenerative changes in the latter, or from their 
complete and final disappearance. Naturally these changes may be 
simultaneous. They are usually effected slowly, and the results are 
persistent. They are frequent concomitants of a long list of other 
pathological alterations. Usually, however, they succeed the latter. 
Under the general title of atrophy of the skin, several rare forms of 
the disease have been considered. 



Atrophia Senilis. 

This is the frequently recognized cutaneous degeneration peculiar 
to old age. The skin becomes colored in various shades of brown, 
either uniformly or in tolerably distinct maculations over the face, 
dorsum of the hands, the genitalia and the anus, and the lower 
extremities. It is seamed with furrows and wrinkles, often in various 
degrees desquamates slightly, and, losing the cushion of fat upon 
which it rested in earlier life, is either readily raised from the sub- 
cutaneous structures, or depends from them in loose folds. Pea- to 
finger-nail sized, verruciform, dirty yellowish accumulations of epi- 
dermis become visible, often in numbers on the face and elsewhere, 
extending either as far as the deeper portions of the horny layer or 
the rete. 

The cutaneous atrophy in such cases may be characterized by 
unusual dryness, with failure of reproduction of the elements of the 
skin after the loss by physiological waste. The epidermis and derma, 



518 DISEASES OF THE SKIN. 

by their shrivelling, lose largely their characteristic interdigitations, 
while the elements of which they are composed are impoverished in 
protoplasm. Vessels, relatively numerous before, disappear ; pigment 
multiplies ; the hairs are either produced as lanugo filaments, or fall 
as the papillae in the fundus of their sacs flatten ; the root-sheaths 
encroach upon the follicle ; while the sebaceous and coil-glands may 
either disappear, or dilate and become filled with an epidermic de- 
tritus. 

In other cases the skin elements undergo a true metamorphosis, 
fatty, lardaceous, amyloid, colloid, waxy, or vitreous. 

Partial Idiopathic Atrophy 

of the skin, occurs always as a result of the stretching or tearing of 
the elastic fibres of the derma. The skin, thus deprived of its normal 
degree of tension, permits at the site of such accident the vascularity 
of the subjacent tissue to be visible to an unusual extent through 
the epidermis, and there results a characteristic dull reddish or 
slightly purplish hue in the lines or areas where the change is 
wrought. In the region involved, an atrophy of the skin and some- 
times a disappearance in part of the vascular plexus result. 

The causes which induce the stretching, the tearing, or the other 
changes in the elastic tissue are exceedingly numerous. Prominent 
among them may be named : traumatism (the persistent marks some- 
times left, for example, by a lash of the skin with a whip, insufficient 
to wound the epidermis but capable of injuring the deeper elastic 
tissue), ascites, anasarca, distention of the body with tumors, preg- 
nancy in women, excessive deposit of fat, and lesions of such disor- 
ders as syphilis and lepra. 



Atrophia Maculosa et Striata. 
(Vergetures.) 

Partial idiopathic atrophy of the skin occurs most frequently in 
linear cicatriform striae or streaks, an inch or more in length, 
developed chiefly about the hips, buttocks, and upper portion of the 
thighs in both sexes of adult years. Less frequently they are observed 
upon the neck, trunk, and extremities. They are insidious of devel- 
opment, indelibly persistent, and appear as sensibly thinned, glisten- 
ing, and often depressed lines or furrows, having a whitish hue, with 
an occasional blending of a very delicate purplish tint. They are 
usually multiple, and at times abundantly displayed, running in 
various curves, for the most part at angles with the long axis of the 
body. They occasion, as a rule, no subjective sensation. 

Much more rarely the atrophic areas occur in macular patches. 
The lesions are then fewer, more isolated, and are discovered more 
frequently upon the extremities, but also on the trunk, varying in 
size from a coffee-bean to a chestnut. This form of atrophy often 



ATROPHIA MACULOSA ET STRIATA. 519 

succeeds either an erythematous or pigmeuted condition, which very 
slowly changes till there is formed the dead white, round or oval, often 
insensitive patch, resembling coarsely a vaccine cicatrix. Taylor, 1 
and Atkinson, 2 have described some very interesting features in this 
process ; and the author has been able to verify the accuracy of their 
observations in several typical cases of the affection. The lesions 
often occur about the ankles of women with menstrual derangements, 
the largest spot often attaining the size of the transverse section of a 
hen's egg. The patches are in various degrees insensitive, very 
slightly depressed, smooth, glistening, and scar-like, the condition 
being the sequel of brown to chocolate-tinted pigmentations, limited 
to the spaces which become afterward atrophic. Cantani 3 describes 
similar atrophic maculae, where there had been a bluish-red color, 
evidently due to the development of minute vascular capillaries. 
The sensibility of the skin was unaltered. Under the microscope 
both the linear and macular lesions show separation of the fibrous 
fasciculi, effacement of the papillary layer of the corium, and 
diminution in the number of vessels and glandular appendages. In 
Taylor's and the author's cases, the maculae were quite hairless ; in 
Atkinson's, the hairs were relatively few in number. 

Fere and Quemonne 4 have also described two singular cases observed 
in Charcot's clinic. In one of these, minute, whitish, elongated 
cicatrices appeared, about which there was a marked pigmentation 
of the skin. They were abundant in the lumbar region. In a second 
case, brownish lines appeared over the breast of an unmarried woman, 
which gradually grew paler, while others appeared over the skin of 
the throat. Those which were recent had a brownish or bluish-red 
color ; others were of a dead white hue ; some appeared over the 
lumbar region and the upper part of the buttocks ; but there was 
none over the belly, the groins, and the thighs. In both cases the 
regions attacked were those in which there was no suspicion that the 
vergetures resulted from the overdistention of the skin. 

These lesions are to be distinguished from the sequelae of sclero- 
derma, syphilis, and other diseases capable of leaving atrophic areas. 
A previous history of such pathological conditions would usually be 
needful ; but in the cases where there is precedent telangiectasis, 
hyperaernia, or marked pigmentation of the spot, the diagnosis, as 
several authors suggest, is attended with some difficulty. 

Partial symptomatic atrophy of the skin, in its simplest form, 
results from the traumatic action of tumors (ovarian, uterine, mesen- 
teric, etc.), by which it is distended. The well-known results of 
a first pregnancy conducted to full term, are linear atrophies, at first 
of a violet tint, and later of a dead whitish hue, which are indis- 
tinguishable, both clinically and pathologically, from the idiopathic 
lesions of similar aspect. Partial symptomatic atrophy, with degen- 
eration of the cutaneous elements (fatty, lardaceous, waxy, etc.), is 
the sequel common to a long list of cutaneous affections. 

i Archives of Dermatology, vol, ii, No. 2, 1867. 2 Rich, and Louis. Med. Journ., Nov. 16,1877. 
3 II Morgani, May, 1881. -t Le Progres Med., Oct. 29, 1881, p. 837. 



520 DISEASES OF THE SKIN. 

Diffuse Idiopathic Atrophy 

of the skin, usually of progressive type, has been described under 
different names by several authors (General Idiopathic Cutaneous 
Atrophy; Atrophia Cutis Universalis; Progressive Idiopathic Atro- 
phy). In these cases the skin over large areas, such as that covering 
an entire limb or the trunk, becomes thin, flaccid, dry, scaly, unpro- 
vided with fat, and brownish or dead whitish in hue. Puncta, striae, 
and plaques, reddish-blue or reddish brown, or even purplish in color 
are to be seen here, marbling the surface and occasionally leaving 
after disappearance a decided pigmentation. The process slowly 
advances over the regions affected. 

Glossy Skin. 

The "glossy fingers" described by Sir James Paget 1 , Gull, Mit- 
chell, and others are tapering, smooth, hairless, unwrinkled, glossy, 
pink, and ruddy, or blotched, as if with permanent chilblains. One 
or several fingers are affected. The condition is associated with neu- 
ralgia or nervous impairment indicated by abormal sensations, as of 
heat or intense burning. There is usually, however, a precedent or 
subsequent neuralgic pain, with incurvation of the nails and at times 
heaping up of epidermal masses beneath the free border of the nail. 
In consequence of retraction of the skin over the distal phalanges, 
the terminal extremity of the digit appears thinned and drawn away 
from the nail-bed. 

The complications of this condition are changes in the sebaceous 
and coil glands, loss of hair about the phalanges, excoriations, and 
in severe cases ulcerations. 

This condition may be associated with grave systemic conditions 
such as lepra, or with gout and rheumatism. It is found also in 
those in whom for any reason the circulation is feeble and there has 
been exposure of the extremities to severe cold. It has also been 
noted as the result of centric and peripheral changes in the nervous 
system. In some cases the cause is recognized as a neuritis ; in 
others it may be more properly classed with the trophoneuroses of the 
skin. The relations of this and several symmetrical disorders of the 
hands and feet to the so-called " perforating ulcer of the foot," 
u asphyxia " of the extremities, " symmetrical gangrene " of the 
extremities, and so-called " dying of the fingers," all manifestly 
trophoneurotic affections (see the chapter on this subject), have not 
yet been satisfactorily established. 

Blanching Atrophy of the Skin. — Several instances of this 
peculiar degeneration of the integument have been observed. It is 
characterized by an unuatural whiteness or pallor of the surface, with 
considerable tension and tenuity of the epidermis, usually limited to 
the extremities (the arms and palmar faces, and the thighs and legs 

i Med. Times and Gaz., March 24, 1864. 



ATROPHIA MACULOSA ET STRIATA. 521 

and plantar faces) ; moderate exfoliation occurs, and the latter, in 
connection with the tension to which the skin is subjected, is respon- 
sible for more or less painful subjective sensations. The disorder is 
chronic in its course, and may originate in infancy. 

This condition is occasionally illustrated by persons affected with 
a sensori-motor paralysis of one limb, when the muscles waste and 
the fat-cells persist, multiply, or wholly disappear. The skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs, at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
yet other cases of trophic disturbance, the skin shrivels and assumes 
instead of a whitish, a yellowish, or yellowish gray tinge. 

Multiple Benign Tumor-like New Growths of the Skin. 

Under this title Schweninger and Buzzi (Internat. Atlas of Rare 
Skin Diseases, v., 1890-91), describe and figure lesions occurring 
on the back chiefly, but also on the arms and chin of a married 
woman twenty-nine years of age. These were bean- to coin-sized, 
bluish-white, and slate-tinted formations, with delicate telangiec- 
tases over the surface of some. By pressure, most of them could 
be forced into a shallow pit in the underlying tissue, the tumor re- 
turning like a ventral hernia after the removal of the pressure. The 
larger seemed to spring from the smaller lesions, and, as they in- 
creased in age, became flatter, less white, harder, and less compressi- 
ble. They produced no subjective sensations, and in no way inter- 
fered with the general health of the patient. The vigorous treatment 
adopted seemed to have but little effect on the growths. 

Under the microscope, sections of the excised skin showed that the 
elastic fibres were in every instance wholly wanting from the affected 
portions, nor were there signs of remnants or of degeneration pro- 
ducts of these elements. It was assumed that there had been in each 
such locality a retraction of the elastic tissue, and that the resulting 
disease was due to a disturbance of the static-balance, the over-growth 
developing till the equilibrium was established. A growth of new 
and young cells was visible about the adventitia of the vessels and 
most of the accessory organs of the skin. 

Kraurosis Vulvae. 

Breisky 1 in Austria, and in this country Heitzmann and Ohmann- 
Dumesnil have described a condition of the vulva in women, affecting 
particularly the labia minora, preputium clitoridis, and the vestibulum, 
in which there occurs a peculiar shrinking, shriveling, or atrophic 
change. The labia minora in some cases wholly disappear, shallow 
furrows taking their place. The clitoris becomes hidden from view 
and may be represented by a minute depression in the membrane. 
The integument covering this thinned or atrophied tissue is whitish, 

' Zeitschrift. f. Heilkunde, Prag. u. Leipzig. March, 1885. 



522 DISEASES OF THE SKIN. 

thickened, roughened, and dry, while the surrounding parts are 
glossy, reddish-gray, or pallid in hue. Of twelve well-marked cases, 
itching was present in but four. Women of all ages from nineteen 
to fifty, suffer from the disorder ; and this irrespective of coitus and 
pregnancy. 

I have had the opportunity of studying with care two well-marked 
instances of this disorder ; and believe that for the present, further 
investigation must be made before its identity can be accepted or its 
nosological position established. The life-history of some of the 
affected patients must be had, in order to gain a complete knowledge 
of the morbid condition. In one of my patients the resemblance 
was very striking to certain indolent epitheliomata of the penis, where 
a remarkable shrinking may at times be produced in consequence of 
metamorphosis of tissue. 



CLASS VI. 

STEW GROWTHS. 

1. Of Connective Tissue. 
Keloid. 

Cheloid, Kelis, Cancroid. Ger., Knollenkrebs ; Alibert's Keloid. 

Gr., xfov, a crab's claw. 

Statistical frequency in America, 0.124. 

Keloid is a benign cutaneous neoplasm, occurring as one or more elevated, whitish 
and reddish, firm, and elastic nodules, plaques, ridges, or radiating stria? ; or 
as several of such forms in combination, resembling an hypertrophied cicatrix. 

The term Keloid, first given to this disease by Alibert, should be 
restricted to it exclusively. The so-called Keloid of Addison, is 
known to-day more properly as scleroderma. 

Authors have described two varieties of this disease; first, the 
"true," "spontaneous," idiopathic form; second, the " false," "spuri- 
ous," or cicatricial. 

The best accepted view of this question is that the condition to 
which this name is given is one and the same under all circum- 
stances. It may occur when there is no evidence of a preceding 
disease or injury, and in that case it has been termed true keloid, 
though the opinion is gaining ground that in these cases there 
has been an ignored cause of the disease. These, in the present 
state of knowledge, may be classed as instances of primary (or true) 



KELOID. 



523 



keloid. Where there has been obviously a preceding disease or 
injury, the keloid condition is consecutive or secondary to the other. 
There is no anatomico-pathological separation between the two. The 
strong probability exists that all cases of so-called "spontaneous 
keloid " are instances of development of the growth in regions of 
pressure, contusion, or traction. 

Symptoms. — The new-formations of this disease are dense, generally 
elastic nodules embedded in the corium, or projecting above the level 
of the skin and firmly attached to it. They are usually very slow of 



Fig. 61. 




Keloid. 



evolution, and, having once obtained their full development and 
assumed one of the several shapes which they affect, usually persist 
for a lifetime. These forms are globular or semi-globular,' whitish 
or reddish nodules, buttons, or plaques, with roundish or ovoid out- 
line ; linear elevated striae, bands, ridges, resembling cords, ribbons, 
or tapes, in irregular outline and disposition ; or combinations of two 
or more of these figures. A common form over the sternum, and in 
other situations where the development of the growth in every direc- 
tion is not impeded, is that of a larger central mass with two or more 
diminishing and declining prolongations bearing a remote resemblance 
to the body and claws of a crab. The lesions vary in size from a 
small pea to a large saucer, the largest including the outlying points 
of the limbs or radiating ridges. Over it the skin is" reddish or 



524 DISEASES OF THE SKIN. 

whitish in color, smooth, hairless, and occasionally hyper-sensitive to 
pressure and heat. The growth is also at times the seat of sponta- 
neous pain. 

The most frequent site of the disease is the anterior surface of the 
chest, but it is observed also upon the face, neck, ears, breast, hands, 
between the scapulae, and on the extremities. It may be encountered, 
indeed, upon any portion of the body. I have seen it upon the penis 
of the negro. It is far more common in the colored than in the 
white races. Though frequently multiple, there are rarely more 
than a score of these growths visible at one time upon the skin of 
one person. 

The variations of keloid are not toward extremes. The overlying 
integument may be wholly uncolored in the white races, and dead- 
whitish in color or even blackish among the negroes. At other 
times the surface is not merely pinkish or reddish, but vividly red 
in hue, the color being evidently produced by vascularization of the 
superficial portions of the growth, new formed vessels, commonly 
largest at the base of the tumors, ramifying freely over the surface. 
The subjective sensations aroused may be trifling or inappreciable ; 
at other times the growths are the seat of severe pain or burning. 
The common course of the disease is toward the production of tumors 
of a medium size, after w r hich few changes are to be recognized. In- 
volution and complete disappearance are rare. These results have 
been reported, however, in a few cases. 

Cicatricial Keloid (scar keloid ; hypertrophic scar ; hypertrophic 
cicatrix) resembles in its features the true keloid described above, and 
differs from the latter chiefly in the fact that it is always preceded by 
scar formation, due either to disease or injury. It thus follows the 
lesions of zoster, variola, and syphilis ; as also traumatisms of all sorts, 
including those made by surgical operations and accidents. The 
tumors, as a rule, spring directly from the scar-tissue, and after 
reaching a maximum of development do not surpass the limits of the 
original lesions ; at times however, the growths slowly develop, as in 
spontaneous keloid, at a distance from the original site of injury or 
disease. Scar keloid is often found as a firm nodule in the lobe of 
each ear among women, after piercing the ear for the insertion of 
ear-rings ; it is seen also, not rarely, as a result of burns, whether 
produced by application of caustic agents or heat. 

Etiology. — The origin of the disease is exceedingly obscure. Neither 
age, sex, nor previous disorder of the skin seems to have any bearing 
upon its production. It is seen in remarkably vigorous persons 
(more often decidedly in the negro race), but also upou those who are 
weakly. The very young and very old are more rarely affected. 

Pathology. — No little confusion has occurred in consequence of the 
attempt to distinguish between keloid and cicatrix. Epithelioma, 
sarcoma, fibroma, and other diseases have existed with or complicated 
keloid, and the anatomical features of the last-named disorder been 
thus obscured. 



CICATRIX. 525 

Though not yet demonstrated, it is probable that eventually some 
varieties of keloid will be recognized as examples of cutaneous tuber- 
culosis. The race in which its lesions are most often and most 
voluminously displayed is exceedingly apt for tuberculous infection ; 
and the frequent recurrence of the disease after surgical excision, 
with the peculiar lupoid aspect of certain keloid lesions are strikingly 
suggestive. 

In all cases of keloid, the papillary layer of the corium and the 
interpapillary projectious of the rete downward are intact The new 
formation is strictly limited to the middle and lower portions of the 
corium, where whitish, tendinous fibres of connective tissue, dis- 
persed for the most part parallel to the surface of the rete, are 
numerous. Lymph-vessels, with proliferated endothelium, com- 
pressed by longitudinal growth of the fibres, pass in both vertical 
and horizontal planes, for the most part remaining patulous. There 
are few spindle cells and nucleated cells. Many of the blood-vascular 
channels are choked or absent. 

Diagnosis. — The clinical distinction between keloid and cicatrix 
is of trifling importance. The situation of the lesions of the former, 
often over the sternum, the infrequency of multiple tumors, its claw- 
like prolongations, and yellowish-white, reddish, or grayish-white 
color, all point to the nature of the disease. 

Treatment. — Removal of keloid by cauterization and excision is 
not to be practised, as the growth does not fail to reappear. Yidal 
has successfully employed multiple linear scarifications. Various 
stimulating applications may also be made with a view to promote 
resorption, such as the spirit of green soap, iodated glycerin, iodine 
in ointment and tincture, and mercurial and lead plasters Where 
there is pain, anodyne unguents may be employed topically, such as 
the freshly prepared belladonna plaster, or the ointments of bella- 
donna, stramonium, and opium. By far the most elegant of these, 
and one which also is capable of producing an alterative effect, is 
the oleate of mercury and morphia, manufactured by Squibb, of 
Brooklyn. 

Internally, quinine, strychnine, arsenic, and the iodide of potas- 
sium have been exhibited with varying success. The author has 
never happened to see a case where internal medication had been 
followed by appreciable results in the diminution of the growth. 

Prognosis. — As regards the general condition of the patient, the 
prognosis is favorable. Very rarely there is spontaneous resorption 
of the nodule or tumor. Generally the latter may be expected to 
persist, after full evolution is attained, for an indefinite period of time. 

Cicatrix. 

Cicatrix is a dense, smooth, whitish or reddish new-formation of the skin, occur- 
ring where there has been a loss of connective tissue following traumatism or 
tissue degeneration. 

A cicatrix, as has already been shown, is a new formation of the 
skin, replacing connective tissue which has been lost by traumatism, 



526 DISEASES OF THE SKIN. 

by ulceration, or by some other pathological process. Most cicatrices, 
as, for example, those following the ulcerations of syphilis, the opera- 
tions of the surgeon, or the dermatitis produced by a severe burn, are 
reparative in their effect. 

They vary greatly in shape, size, color, and other characteristics. 
They may be smooth, glossy, shining, scaling, dull-whitish in color, 
or pinkish from vascularization of the surface. They may be linear, 
fan-shaped, circular, corded, ridged, dotted, crateriform, or tumor- 
like. They may be raised above the skin, on a level with it, or de- 
pressed below it. They may be deeply attached to periosteum or 
boue, or be readily movable over the panniculus adiposus. They 
are of deeper color when young, and increase in whiteness with age. 
They are unprovided, as a rule, with hairs, or coil- or sebaceous- 
glands. 

The most insignificant cicatrices are those resulting from cleau, 
incised, and punctured wounds and lesions of similar grade. Here 
the wounded surface furnishes a connective tissue that seals up the 
solution of the contiuuity. Healing is then said to be by " first in- 
tention," and is at at end, so far as regards the gross appearances, in 
one to two days. 

Healing by u second intention " occurs after a louger period, in 
solutions of continuity of greater extent, and in those of the same 
extent in aseptic conditions. Here also newly formed connective 
tissue concludes the successive transformations from epithelium and 
leucocytes to embryonal vessels, pus, plasma, and cicatrix. 

Certain peculiarities of cicatrix are seen in special disorders where 
they are produced. The circular, oval, reniform, horseshoe-shaped, 
S-shaped, and figure-of-eight-shaped scars, thin and flexible, are 
characteristic of syphilis. The cicatrices of variola, zona, and 
ecth}^ma are slightly different each from the other, though all are of 
small size and depressed. Those of tuberculosis and dermatitis 
calorica of severe grade, are exceedingly irregular and often 
corded. 

Hypertrophy of cicatrices is the coudition already described as 
keloid. Here there is a tumor-like development of the cicatrix, 
forming a ridge, button, knob, indurated fold, or puckered and 
irregularly circumscribed, whitish or reddish lesion. 

These follow almost every traumatism and destructive process to 
which the integument is liable. 

A case of cicatrix undergoing involution has been described by 
Dyce Duckworth, iu a man aged fifty, who suffered from rheumatic 
fever, on two occasions, ten years before the date of report. He had 
pericarditis, and was blistered over the prsecordia. Nine months 
afterward, lines of cicatricial growth began to form in the scar left 
by the blister, and they exteuded rapidly. In two years 7 time they 
were still enlarging. In seven years, some subsidence was noticed, 
and, when exhibited ten years after their first formation, involution 
was markedly progressing. The case illustrates the frequent origin 



CICATRIX. 527 

of scar tissue, its common occurrence over the sternum, and the fact 
of the subsidence of the new growth in the course of time. 1 

Clulton 2 reports a case of cicatrix following erasion of a lupous 
patch, an issue which may be regarded as the most fortunate for any 
case. 

Purdon 3 announces the same result following a psoriasis treated 
with green soap ; and Taylor 4 reports the same as a rare result of 
syphilis. 

Keloid-] ike cicatrix of the cheeks is far from uncommon follow- 
ing acne. Its lesion is usually smoothed down in the process of time, 
after the disappearance of the sebaceous gland disorder, till the 
deformity is greatly lessened, and often scarcely noticeable. 

Etiology. — The formation of a cicatrix is always preceded by a 
traumatism or pathological loss of tissue, the remote causes of which 
have the widest possible variation. Hypertrophied cicatrix is always 
developed from a simple scar. It affects persons of all ages and 
sexes, but with decided preference for the negro race. The trauma- 
tism may occur from piercing the ears for ear-rings, the operations of 
surgery, leech-bites, the deeper burns from fire, and wounds inflicted 
by accident. It often follows cutting the hands with glass ; and has 
been caused by the spur of a cock. It is sufficiently common after 
the occurrence of acne indurata, but the latter is of all its forms the 
least persistent. In general, it may be concluded, however, that it 
occurs chiefly in those whose skins have a special tendency to such 
development. 

Pathology. — Kaposi has demonstrated a difference, rather of dis- 
position than of kind, between keloid, hypertrophied cicatrix, and 
" cicatricial keloid." In the first, the epidermis is described as 
intact, w T hile the corium at one level exhibits whitish, thickened, and 
closely packed bundles of fibrous elements, lying parallel to the loug 
axis of the tumor and the surface of the skin, traversed here and 
there diagonally by similar bundles, all probably derived originally 
from the sheaths of the bloodvessels. In the second, the papillary 
layer of the corium has been destroyed by the process of which the 
cicatrix is a resultant, and the latter does not surpass its original 
limits by invading the unaltered peripheral tissues. The connective- 
tissue bundles are here also much less closely aggregated. In the 
third, the two forms described above can be seen combined, the 
papillary layer being destroyed, and the peripheral parts invaded by 
the connective-tissue new growth. 

Diagnosis. — The distinction between hypertrophied cicatrix and 
keloid is one chiefly of degree and needless from a practical point of 
view. Following the piercing of the lobule of the ear for the inser- 
tion of ear-rings, the lesion is distinguishable by pinching the part 
between the fingers, when a globular, pea- to cherry-sized mass will 
be felt firmly embedded in the derma between the reflected folds of 
the integument. Upon the face, after the occurrence of acne, it can 

i Brit. Med. Journ., October 8, 1881, p. 597. 2 ibid., January 20, 1883. 

s Journ. of Cutan. and Vener. Dis., 1883, p. 203. 4 Ibid., 1883, p. 308. 



528 DISEASES OF THE SKIN. 

be usually seeu as a puckered ridge, often transverse in direction, 
occupying the region of the cheek. 

Treatment — The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautious 
are observed. The treatment of pathological conditions likely to be 
followed by cicatrices is the treatment largely of the special disease 
in which such loss of tissue occurs, e. g., the ulcer left by a degener- 
ating syphilitic gumma of the skin. 

The treatment of hypertrophied cicatrix is the treatment of keloid 
already given. 

Fibroma. 

Lat., fibra, a fibre. 

Fibroma Molluscum ; Molluscum Pendulum. 

Statistical frequency in America, 0.075. 

Fibromata are cutaneous or subcutaneous neoplastic tumors, projecting in dif- 
ferent degrees from the surface, single or multiple, of several grades of 
density, distinctly circumscribed, covered either by a sound and attached, or 
rarely by an ulcerated integument, and varying in size from a small pea to 
a foetal head. 

Symptoms. — Fibroma is a disease characterized usually by the 
occurrence of numerous, roundish, softish, semi-solid, or solid growths, 
varying in size from that of a small pea to tumors of several pounds 
weight, though more rarely the neoplasm is single. They are often 
called molluscous fibromata, as the disease was termed at one time 
molluscum fibrosum. When quite small they are seated within or 
beneath the skin, where they can be distinguished as distinctly cir- 
cumscribed nodules, buttons, or plaques often slightly projecting. 
When more fully developed they become sessile, pedunculated, or 
largely pendulous tumors, hanging from the part to which they are 
attached so as to resemble in shape a cherry, a nipple, a pear, or a 
sausage. They are commonly covered by an integument which is 
natural in color and suppleness, though the latter may be traversed 
by bloodvessels ; sprinkled with comedones or patent orifices of seba- 
ceous gland ducts ; thinned or thickened, or in a state of ulceration ; 
the Jast named being usually the result of externally operating causes 
in tumors of large size. They are productive of no subjective sensa- 
tion beyond the more or less uncomfortable tension produced by the 
weight of those attaining a great size. When multiple, they may be 
seen in various degrees of development, covering in hundreds, and 
even thousands, the entire body, especially the scalp, face, trunk, 
genitals, and extremities. Upon the lids, they may interfere with 
vision by the production of ptosis. To the touch, they may be felt 
as softish, somewhat elastic, firm, or lobulated masses, though at 
times nothing but a double fold of skin can be perceived, or a cord- 
like contained body. 

They are often congenital. When closely set together upon the 



PLATE V. 




MULTIPLE FIBROMATA OF THE BACK. 

From a photograph of one of the author's patients. 



FIBROMA. 



529 



skin, and of small size and pendulous, the features of the disease 
are characteristic. 

Schwimmer distinguishes between these lesions, usually congenital 
(termed by him, soft fibroma), and the dense tumors of similar 
anatomical features (termed by him, firm, or hard, fibromas). The 



Fig. 63. 




Multiple fibromata. (Gross.) 



Large single fibroma. (From a photograph 
of one of the author's patients.) 



latter are circumscribed, deeply seated, very slow of development, 
and apt to induce changes in the tissues which surround them. They 
may undergo fatty degeneration, or ossification, or calcification. 

Dr. R. W. Taylor, of New York, 1 in an interesting paper on the 
mode of development and course of fibroma, and its relations to 
acrochordon and other cutaneous offshoots, describes the first appear- 

1 Journ. of Cutan. and Genito-urinary Diseases, Feb., 1887. 
34 



530 DISEASES OF THE SKIN. 

ance of the disease as a roundish spot over which the skin is uplifted. 
It is of a light pinkish color. The tumor is soft and suggests to 
the touch a thinning of the derma beneath. By firm pressure over 
such lesions when they have in size attained about half an inch in 
diameter, they may be slowly pushed downward into the skin, and 
the sensation is produced to the touch, of a foramen in the derma. 
Fusion between the new growth and the skin over it is of early 
occurrence. The roundish or oval form of the tumor depends upon 
the direction of the bundles of the subcutaneous tissue of the part 
invaded. After reaching full development, it may be replaced by 
warty growths, pouches, or nipples. Involution is more common 
when the patient is under thirty years of age. Dermatolysis is pro- 
duced by great activity of the growth of one, or fusion of several 
tumors, by which a flap of skin is formed. 

The large tumors in the skin of the patient carefully studied by 
Taylor, suggested, when handled, that they contained boiled vermi- 
celli, or a number of thread-worms, and contrasted thus with the 
firm or semi-solid lesions of older patients affected with fibroma. 
The soft and gelatinous quality of the neoplasm in earlier life is 
believed to be proportioned to the age of the subject, and this rapid 
development and succulency of structure are the only conditions of a 
perfect involution which are not to be looked for in the firmer, more 
slowly growing fibromata of later years. 

When involution occurs, after full maturity of the lesions has been 
attained, the softish contents of the tumors are adherent to the cutis 
above, and the cutaneous atrophy is proportioned to the rapidity of 
development of the growth and the firmness of its structure. Then 
comes a purse-like pedunculation of the tumor, produced by encroach- 
ment of the skin upon its pedicle, rendering its invagination, sup- 
posably possible before, afterward difficult or impossible. Then 
gradually the neoplasm loses its skin-connection. Eventually, in 
many cases only fibrous cords are left, evidently attached to the con- 
nective tissue beneath, the skin color paling as the vascular tension 
correspondingly diminishes. Soon the dermal foramen closes, and 
the involution process is at an end. Then empty and wrinkled 
pouches or purses of integument are left, whose further shrinking 
produces multiple warty or nipple-like elevations of tissue (under the 
microscope recognized as fibrous structures with epithelial envelope), 
much in color like the virgin nipple, or the scrotum of a boy. From 
four months to a year was requisite for the mature development of 
the tumors, and nearly as long a period for the completion of the 
process of involution. The dermatolytic flap was permanent. Dr. 
Taylor believes, as a result of his interesting study, that there is the 
closest possible relation between fibroma and the verrucous growths 
called acrochordon and ecphyma mollusciforme. 



DERMATOLYSIS. 531 

Dermatolysis, 

(Chalazodermia ; Pachydermatocele ; Lax, or Relaxed Skin,) 

is a condition, which, as appears in what precedes, may be pro- 
duced by fibroma and follow the involution of its lesions. In 
other cases it is apparently spontaneous and diffuse, but then proba- 
bly the result of some preceding condition which has been unnoticed. 
The skin of patients thus affected is in a condition resembling that 
of the young of several of the larger among the lower animals (pups 
of large hounds, etc.), where enormous flaps of skin may be gathered 
up between the fingers and carried away from the underlying tissue 
so that the inferior surfaces of the integument may be approximated 
over large areas. The skin in these cases is usually thickened, but it 
may be stretched to a considerable tenuity, as in the case of a man 
lately exhibited in this country who could cover his face with a 
species of veil removable from the surface of the chest. The integu- 
ment may be externally normal to the view, or pigmented. It may 
be the seat of molluscous tumors; aud either insensitive, or normally 
sensitive, or the seat of painful sensations. Usually all the functions 
of the integument are preserved. 

The anomaly is always partial and limited to either the face (the 
lids), the neck, the chest, the belly, or the genital region. The dis- 
ease may be congenital or acquired. 

Dermatolysis, as thus recognized, is to be distinguished from the 
laxity of skin apparent in the senile condition and after distention 
from the presence of tumors, pregnancy, etc. Usually, however, in 
the latter cases, it is the subcutaneous tissues which are relaxed rather 
than to any unusual extent the skin itself (e. g., the mammary glands 
of women of advanced years, and the abdominal muscles after dis- 
tention of the belly). 

Etiology. — The disease is peculiar to neither sex ; and, though 
observed in adults, is commonly first developed in childhood. It 
cannot be claimed as peculiar to any race, though in this country the 
negroes have probably furnished the largest field for its observation. 
Hebra called attention to the low standard of physical and mental 
development of the subjects of the disease seen by him, a fact well 
illustrated in a case recently presented at the author's clinic, the 
patient being an exceedingly myopic, poorly nourished, white, male 
dwarf, whose body was literally covered with fibromata from the scalp 
to the feet. In view of this well-established clinical fact, the heredita- 
bility of the disease, which is rendered probable by recorded observa- 
tions, seems capable of explanation. It has been noted in three 
successive generations and in several children of one family. The 
precise cause of the disease is unknown. It is, however, reasonable 
to conclude that it is due to a vice of local development under the 
influence of a constitutional predisposition. 

Pathology. — Fibromata originate in gelatinous connective-tissue 
elements, which undergo metamorphosis into bundles of fibres, the 



532 DISEASES OF THE SKIN. 

tumors always exhibiting more of the formed material in the outer, 
and the formative or protoplasmic material in the central parts of the 
mass. The fibrous bundles pass downward, and unite with those of 
the derma or subcutaneous tissue, forming thus a firm attachment for 
the pedicle of all pedunculated tumors. There is some question as 
to w T hether these growths originate in the deep interspaces of the 
corium or in the connective tissue about the hair-follicles or fat 
lobules. 

Heitzmann 1 divides the fibrous tumors of the skin into two classes : 
" a. Dense, fibrous, connective-tissue bundles with relatively few 
spindle-shaped protoplasmic bodies or solid nuclei running in all 
directions, apparently without any regularity, thus producing a hard 
and dense felt-like tissue. This is an imitation of the structure of 
aponeuroses or interarticular ligaments, if scantily supplied with 
bloodvessels ; or of periosteum and perichondrium, if holding a larger 
number of bloodvessels. 6. Dense, fibrous, connective-tissue bundles, 
holding in their meshes a jelly-like basis substance, with a small 
number of protoplasmic bodies. This variety is an imitation of the 
structure met with in the valves of the heart mainly upon their inser- 
tions. The supply of bloodvessels, as a rule, is scanty. Both 
varieties are common tumors of the skin, in the shape of hard, sessile 
nodules and nodes (hard fibroma) ; or tumors of greatly varying size 
but softer consistence (soft or myxo-fibroma) ; or shallow, as a rule 
pigmented elevations of the skin (nsevi) ; or scar-like, irregularly 
branching, sometimes freely vascularized new formations (keloid)." 

A very large number of fibromata are of the so-called " mixed " 
variety. Some spring from the nerve-sheaths, and actually contain 
nervous filaments (neuro-fibroma) ; others from muscular, vascular, 
and glandular tissues, the compound tumor receiving in this way a 
part of its constituent elements ; often warty growths form with par- 
ticipation of epithelium in the connective tissue, constituting thus an 
epithelioma (so-called " papilloma "). The large pendulous tumors 
of nsevus lipomatodes may be examples of mixed fibromata whose 
surface is composed of pigmented and hairy skin. 

Diagnosis. — The tumors of molluscum fibrosum are to be distin- 
guished clinically from multiple cutaneous sarcomata, by the viola- 
ceous or reddish color of the latter, their absence of pedunculation, 
their greater tendency to ulceration, and their evidently malignant 
character. From the tubercles of lepra they are differentiated by the 
entire absence of constitutional impairment and their general develop- 
ment in far greater multiplicity. The tumors of molluscum epithe- 
liale differ in their contents, superficial location, and in the frequent 
presence of the dark punctum at their summits. 

Neuroma is usually painful ; lipoma less frequently multiple aud 
pedunculated, and more suggestive, when handled, of the " pillowy " 
sensation to the touch. Warty growths are readily distinguished by 
their verrucous summits ; and the gummata of syphilis, by the con- 
comitant or prior symptoms of the existence of lues. 

i Archiv. of Dermat., October, 1880, p. 378. 



NEUROMA. 533 

Treatment. — The treatment of large single fibromata is surgical, 
involving the employment of knife, ligature, ecraseur, or galvano- 
or ther mo-cauterization. Multiple lesions are often so numerous as 
to forbid such interference. When there is a distiuct vice of devel- 
opment or inherited tendency to the disease, little can be accomplished 
in the way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their 
evolution is completed. Marasmus, tuberculosis, and a fatal result 
may occur. One or several of the tumors may become sources of 
danger from the occurrence in them of an active inflammation with 
resulting degeneration and septicemic consequences. The disease, 
however, does not, in many cases, shorten life. In general, the prog- 
nosis of multiple fibromata may be regarded as unfavorable. 



Neuroma. 

Gr., vevpov, nerve. 

Neuroma is a disease characterized by the occurrence of single or multiple, pin- 
head to small nut-sized, usually painful cutaneous papules or tubercles, consti- 
tuted of a new growth of connective tissue and non-medullated nerves. 

Symptoms. — But few cases of this rare disease are recorded. The 
description appended is a summary of the symptoms detailed in the 
reports of Duhring, 1 of Rump, 2 and of Kosinski. 8 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks, numerous 
disseminated and defined, pin-head to hazel-nut sized, roundish or 
oval nodules or tubercles. They were either painful, or painless at 
the onset and painful later. Iu Rump's case, which was a sample of 
the false neuromata of Virchow (fibroid tumors of the nerve), there 
was no pain throughout the course of the disease. 

The nodules were not arranged along the tracts of nerves ; were 
immovable, dense, and elastic; were fixed in the corium, and ex- 
tended below it. They were purplish to pinkish in color ; and the 
skin between them was unaltered, or like that enveloping the lesions, 
dry, uneven, and desquamative. The tubercles were both tender and 
painful, the pain being excruciating, paroxysmal, usually lasting in 
Duhring's patient for an hour, and radiating. It was aggravated by 
temperature changes, mental emotion, and movement. 

Sections of the growth in Duhring's case showed anatomically a 
connective-tissue stroma, interwoven with fibres for the most part 
lying parallel with one another, each fibre composed of a finely 
granular central substance surrounded by a sheath containing numer- 
ous, elongated, oval, somewhat granular nuclei. There were also 

1 Case of Painful Neuroma of the Skin. Araer. Journ. of the Med. Sciences, October, 1873 ; 
also Supplement to the same, with cuts. Amer. Journ. of the Med. Sciences, October, 1881. 

2 Arch, of Path Anat,, Bd. Ixxx., Hft. 1. 

3 Centra lblatt f. Chirurg., 1874, No. 16. 



534 



DISEASES OF THE SKIN 
Fig. 64. 




Neuroma of the skin ; external appearance. (Duhring.) 
Fig. 65. 




Microscopic structure of neuroma. (Duhring.) 



XANTHOMA. 535 



yellow elastic tissue, bloodvessels with thickened and nucleated walls, 
and about the latter lymphoid, cell-like bodies. There was entire 
absence of unstriated muscular and fibrillar connective tissue. The 
specimen was certainly unique, representing the true amyelinic neu- 
romata of Virchow. In Kosinski's case, non-medullated nerve fibres 
and connective tissue were also discovered. In both cases exsec- 
tion of a portion of nerve (brachial plexus, of the one ; and small 
sciatic, of the other) was followed by considerable diminution of pain, 
and almost entire disappearance of the growths. In Rump's case, 
which, as stated above, represented the fibromata and so-called fibro- 
nucleated tumors of Virchow, the nodules were strung upon the same 
nerve. " like beads upon a rosary/' and were similarly displayed upon its 
branches. Spinal, cerebral, and sympathetic fibres were all involved. 
Duhring, in commenting upon these interesting cases, calls attention 
to the distinction between these purely cutaneous lesions and the 
generally solitary, movable, and " painful subcutaneous tubercle." 



Xanthoma. 

Gr., %avdoq y yellow. 

Xanthelasma ; Vitiligoidea. Fr., Plaques jaunatres des Paupieres, 

Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or 
grouped, occasionally symmetrical, flat or slightly elevated, yellowish macules, 
papules, or tubercles, which are most commonly situated upon the eyelids. 

This affection was first described by Rayer, 1 and its clinical divis- 
ions established by Addison and Gull. 

Symptoms. — The lesions of Xanthoma occur in (a) plane forms ; 
(b) papular and tubercular forms ; (c) as tumors. These may be 
commingled in one person. 

The macular symptoms of the disease are bean- to fingernail-sized 
plaques, either quite flat or with slightly elevated borders, often con- 
stituted by an aggregation of millet-seed- sized lesions, and covered 
with an apparently normal integument. In color they vary from 
light and chrome yellow to the " coffee and mUk" shade; and in 
shape they may be puuctiform, roundish, oval, elongated, or quite 
irregularly grouped. They are distinctly circumscribed, and when 
gathered between the thumb and finger do not produce the sensation 
of the presence of a foreign material. The plaques, examined closely, 
are seen to be compounded of fine yellowish nodules, each provided 
with a somewhat reddish central point. They are most often seen 
upon the eyelids near the inner canthus, where they may be sym- 
metrically disposed about the two orbits, first appearing on the left 
side. But they may invade also the peri-orbicular region, as also, 
rarely, the cheeks, the nose, the ears, and the nucha. They are 
rarely productive of subjective sensation, being occasionally the seat 

1 Traite prat, des Maladies de la Peau. Paris, 1830. 



536 DISEASES OF THE SKIN. 

of slight pruritus. This is the commoner form of the disease, and 
is termed Xanthoma Planum. 

The papular and tubercular lesions of the same affection, known 
as Xanthoma Papulatum and Tuberculosum, may coexist with 
the plane lesions described above, and scarcely differ from the latter 
save in their greater development. They are whitish or yellowish 
papules, plaques, and tubercles, circumscribed in contour, millet-seed 
to nut-sized, and at times much larger, covered with an unaltered 
epidermis, and determinable by palpation as having greater consist- 
ence than the flat macules. They are less frequently seen upon the 
lids, but occur upon the scalp, cheeks, palmar and plantar surfaces, 
the genital region, and about the joints of the digits. 

The tumors of xanthoma are sessile or pedunculated, cutaneous or 
subcutaneous in attachment, nut to hen's egg in size, originating in 
one or another of the lesions named above, and are described by Cary 1 
and Chambard. 2 To these the name Xanthoma Tuberosum is 
often given. Xanthoma Multiplex is the form in which the 
lesions, usually first manifested in the sites of election and in their 
simplest development, proceed to a gradual invasion of the trunk and 
extremities. Occasionally the mucous surfaces of the mouth, of the 
respiratory and gastro-intestinal tracts are involved, as also of the 
surfaces of the peritoneum, endocardium, and larger arteries. The 
genital region, palate, oesophagus, spleen, trachea, and cornea have 
all been recognized as seats of the disease. 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply embedded in the corium, 
elevated to the extent of one-fourth to one-half of an inch above the 
general level of the integument, and irregularly furrowed or tabu- 
lated superficially. An illustration of xanthoma occurring in full 
development and in rare situations, taken from a photograph of one 
of the author's cases, is presented in the plate appended. 

Other cases in my charge have displayed unusual features of this 
disease. In one there were flattened ribbons, exhibiting xanthoma- 
tous changes in both palms, stretching at right angles to the long 
axis of the hand ; in a second and somewhat rare form of the dis- 
ease, isolated xanthomatous papules were attached somewhat regu- 
larly to the edges of the lids of both eyes, upper and lower equally, 
while large pin-head sized and equally isolated yellowish masses were 
visible below the orbits on each cheek. 

In many cases the disease is accompanied by a generalized colora- 
tion of the skin in a yellowish shade, which has been variously inter- 
preted as a xanthomatous dyschromia and as a true icterus. The 
former is the more probable explanation of the fact, as in such cases 
the urine and viscera have been found normal. 

Korach 3 has described the interesting case of a woman twenty-five 

1 Ann. de Derm, et de Syph., 1880, p. 75. 

- Archiv. de Phys. norm, et path.. Sept. and Dec, 1879. 

3 Deutsch. med" Wochenschrift, No. 20, 1881. 



Plate VI. 









Xanthoma of the H an ds, Elbows, and Knees . 
( From a Photograph of one of the author's patients.) 



XANTHOMA. 537 

years old suffering from chronic icterus produced by closure of the 
ductus choledochus. Beside the typical patches of xanthoma on the 
lids, the skin surface was generally and similarly affected. Thus 
the extensor faces of the extremities, the palms of the hands, nates, 
and other parts were extensively covered with sago-grain to pepper- 
corn sized papules and tubercles of xanthoma, both flat and elevated. 

Occasionally the tubercles exhibit a fine vascularization ; and when 
there is a coincident jaundice the skin between isolated lesions is also 
tinted with the color of the xanthoma nodules. The jaundice, so 
called, is rather more common in the multiplex forms ; and even 
when not readily recognized, the skin, at first sight of normal 
tint, is seen to be somewhat deeply colored in a shade of reddish- 
yellow. The regions of greatest pressure, outside of the lids and 
cheeks, seem sites of preference, as, for example, over the elbows, 
knees, palms, and buttocks. The mucous membranes may exhibit 
well-marked involvement (conjunctivae, tongue, inside of lips, and 
entire surface of mouth, palate, pharynx, larynx, trachea, bronchi, 
oesophagus, vagina, rectum, peritoneal covering of the viscera, and 
the sheaths of the tendons). As a rule, there is scarcely distinguish- 
able subjective sensation, patients commonly applying for relief of 
the resulting facial disfigurement. Occasionally burning and prick- 
ing, and rarely even painful sensations are produced. The patient 
whose lesions were selected for illustration of this chapter subse- 
quently had the tumors removed from his limbs in order to relieve 
himself of discomfort in his work. 

The course of most cases is toward a maximum of development, 
after which the process ceases. In a few instances, usually not pal- 
pebral, complete involution has spontaneously occurred. The varia- 
tions noted in the color of the plane and elevated forms of xanthoma 
are from a light yellow to a deep brownish and even blackish hue. 
Cases occurring in children and infants seem to exhibit nearly the 
same features as those seen in adults. 

Etiology. — The causes of the disease are obscure. In a few cases 
the lesions are first observed in early childhood, though they are 
encountered chiefly in middle and later life. Women are rather 
more often affected than men. 

In some cases the disease would seem to be inherited ; Dr. Bar- 
low 1 reports one such congenital case. Hutchinson and Church 
have reported several instances where more than one member of 
a single family suffered from the disease ; and the mother of the 
patient exhibiting multiple lesions upon the elbows and knees 
selected by the author for illustration, presented plane lesions of 
xanthoma near the inner canthi of the eyes. The association of 
xanthoma with disease of the liver, rheumatism, gout, ovarian dis- 
ease, migraine, syphilis, carcinoma, hydatids, and other disorders 
cannot be denied for certain cases. In the majority, no such associa- 
tion can be recognized ; and careful post-mortem examination of 

1 Path. Soc. of London, 1884. 



588 DISEASES OF THE SKIN. 

patients affected with xanthoma, and dead of intercurrent disease, 
has either demonstrated a normal condition of the liver or a disorder 
of it quite disconnected with xanthoma, such as a stricture of the 
bile-ducts from cicatricial contraction. In some reported cases, 
occurring in diabetic subjects, three women and one man, the eye- 
lids were unaffected, and the partially xanthomatous lesions transitory 
in duration. (See Xanthoma Diabeticorum.) 

The author has reported a single case coming under his observa- 
tion, where multiple plane lesions of the lid in a middle-aged woman 
succeeded a dermatitis of that region, induced by accidental contact 
with a corrosive solution of mercury. 

Pathology. — Pathological studies of the affection have been made 
by Chambard, whose conclusions are briefly these : " The forms 
recognized as plane, tubercular, and tuberose are the results of two 
processes, irritative and retrogressive; the first prevalent in the 
tubercular and tuberose forms, the last in the plane variety. 

" In xanthoma planum, the irritative process is represented by an 
albuminous tumefaction of the connective-tissue elements, with pro- 
liferation of their nuclei; the retrogressive process, by a fatty de- 
generation of their protoplasm. In the other forms, the irritative 
process is distinguished by the new formation of connective tissue ; 
the retrogressive by a fatty infiltration of the old and newly -formed 
connective-tissue elements. In both forms, not only the connective 
tissue of the derma, but also the vascular, glandular, and nervous 
organs, within and about the sclerosed nodules, are invaded. The 
sclerotic process involves also the fibrous envelope of the sebaceous 
and sudoriparous glands (periadenitis) ; the internal and external 
sheaths of the vessels (periarteritis, endarteritis obliterans) ; and the 
lamellar sheath and intra-fascicular connective tissue of the nerves 
(perineuritis, endoneuritis). The nervous involvement is thought to 
explain not only the pain, but also the tenderness peculiar to the 
xanthelasmic tubercles." 

Balzer's conclusions as to the parasitic nature of the disease have 
not been verified by Hanot and Eichoff. 1 

In the careful and exhaustive paper by Dr. Karl Touton 2 it is 
clearly shown that the disease is due to an atypical new formation of 
cells seated in the corium. These have a sharply defined membrane ; 
and a large, roundish, or ovalish nucleus. All parts are thickly 
studded with fat drops, and it is from these that the yellow coloring 
of the xanthoma plaques is derived. They originate in and near the 
lymph spaces and conduits of the derma ; and in the building up of 
the lesions are associated chiefly with connective and yellow elastic 
tissue. The sebaceous glands are not, as was once held by Hebra, 
Geber, and Simon, concerned in the process. The epidermis super- 
imposed upon the lesions may be thinned, but is otherwise pathologi- 
cally uualtered. 

Diagnosis. — Milia are occasionally associated upon the lids in the 

1 Deutsche med Woch., No. 4, 1884. 

2 Viertljst. f. Derm. u. Syph., Hft. 1, 1885, p. 3. 



XANTHOMA. 539 

form of oval plaques, but are distinguishable from xanthoma by the 
possibility of expressing their contents. 

The diagnosis from all other lesions is readily made, when con- 
sideration is had of the peculiar yellowish or saffron-like hue of 
xanthoma, and the common situation, form, and general character- 
istics of its plane or nodular lesions. 

Treatment. — Erasion and excision are the usual methods of remov- 
ing xanthomata. Care should be taken in such operations to avoid a 
consequent ectropion when the operation is performed upon the skin 
of the eyelids. The Paquelin knife, which I have employed for this 
purpose, is objectionable on account of the radiation of the heat to 
the globe of the eye. With the tumor slipped through an aperture 
in a thin sheet of asbestos paper, such as is now found in the mar- 
kets, this inconvenience might be avoided. 

The more modern method, however, of electrolysis is far preferable 
to others. Caustics also have been successfully employed. Besnier 
employs phosphorus internally, followed by turpentine, by which 
course the disease is said to have been relieved. Wilson, with the 
same end in view, employed nitro-muriatic acid, arsenic, bitters, and 
blue pill. 

Prognosis. — The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
The French authors, who have given considerable attention to this 
subject, are disposed to believe that some cases of xanthoma tubero- 
sum, with permanent xanthochromia and involvement of the inner 
coats of the larger vessels, may prove serious. 



Xanthoma Diabeticorum. 
(Glycosuric Xanthoma.) 

This rare disorder has been well illustrated by three excellent por- 
traits showing the features of the disease in a case reported by Dr. 
Robinson, of New York. 1 Instances of this disease have been also 
reported since the cases of Addison and Gull (1851), by Hillairet, 
Morris, Chambard, Hardaway, Barlow, Fox, Crocker, Cavafy, and 
others. 

Symptoms. — The lesions are usually multiple and numerous, dis- 
crete or confluent, and not rarely grouped, pin's-head to pea-sized, 
firm, well defined, conical or acuminate papules. At the apex may 
be recognized a yellowish centre with reddish areola, which may be 
temporarily made to disappear under pressure. The appearance, 
when viewed at some distance, is suggestive of a pustule. Subjective 
sensations of itching, pricking, etc., may be produced. They are 
visible over the buttocks, loins, elbows, knees, and extensor faces of 
the limbs in general, the face (brows, nose), the scalp, about the ankles, 
and over the mucous surface of the mouth, and the palms aud the soles. 

* International Atlas of Rare Skin Diseases, iv. 1890, ii. 



540 DISEASES OF THE SKIN. 

The eruptive lesions are apt to be sudden of occurrence. After re- 
maining upon the surface for a few months or years they may wholly 
disappear without leaving a trace of their existence, or the eruptive 
elements may in part only disappear. 

Etiology. — In all cases glycosuria has been recognized. The 
majority of the patients have been male subjects, and usually in a 
condition of fair nutrition. 

Pathology. — Crocker, who examined sections removed from Mor- 
ris's patient, recognized merely elongation of the rete pegs and some 
eularged papillae with partial obliteration of others. Round and 
oval cell masses surrounded the vessels, the sweat ducts, and the 
lobes of the sebaceous glands. There was some vascular dilata- 
tion. 

Diagnosis. — Those who would make this form of xanthoma sepa- 
rate from all others base the differences between them upon the 
following points : In xanthoma of glycosuria, the sudden evolution 
aud involution of the cutaneous lesions ; the firmness and solidity of 
the latter as distinguished from the softness of the ordinary forms ■ 
and the inflammatory character of the former as distinguished from 
the keratosic qualities of the latter. In xanthoma diabeticorum the 
yellowish apex is not at first apparent nor in all the lesions, and 
when it exists, is due to epidermal changes and not those occurring 
in the corium as in xanthoma. Other characteristic points of the 
xanthoma of diabetic subjects, are the absence of striae and patches, 
the absence of jaundice and of eyelid lesions, the presence of marked 
subjective sensations, the grouping of the lesions about the hair- 
follicles (well marked in Robinson's case), and the absence of diabetes 
mellitus in most of the palpebral cases on record. 

On the other hand it is urged by Besnier and Doyon, that the 
glycosuria is simply an irritating cause which explains the differing 
symptoms of xanthoma in the two classes of patients. 

Surveying the literature of xanthoma they find patients without 
diabetic symptoms suffering from atrocious pruritus and most of the 
special features claimed as peculiar to diabetic xanthoma of glyco- 
suria. I have recorded an interesting case of a patient sent me by 
my colleague, Dr. Purdy, whose treatise on the diseases of the kidney 
has directed his studies to this subject. The patient was a woman in 
middle life, recognized by him as the subject of diabetes mellitus 
(not insipidus), whom I examined with special care. She exhibited 
the common form of symmetrical and plane eyelid lesions. 

In the present state of knowledge on this subject, it is well to 
defer assigning more than a provisional position to this variety of 
the disease. It is quite probable that its features may be one day 
recognized as associated with other affections than those of the 
kidney. 

The Treatment of the disease is largely that of the glycosuria. 
Robinson's patient recovered after the use of small doses of Fowler's 
solution. Local treatment may be employed as indicated in any case. 

The Prognosis is favorable, all cases eventually recovering. 



ADENOMA. 541 



Adenoma. 



Gr., ddf/v, a gland. 

Adenoma is a new growth constituted in part of the cells of the glands and 
of their investing connective tissue found in the skin. 

Adenoma of the Sebaceous Glands ( Adenomes sebaees, of 
Balzer and Menetrier ; Adenomes sebaees cancro'idaux ; Acne can- 
croidale). The several forms of adenoma of the sebaceous glands are 
usually assigned to two categories, the benign and the malignant. 

Acquired benign growths are pin-head to pea-sized, sessile, 
roundish, oval or acuminate bodies, occasionally presenting points of 
whitish appearance suggestive of milium. They are situated chiefly 
over the face (forehead, furrows beside the nares). They are always 
covered by an unchanged epithelium and in color present the hue of 
the normal skin. 

Congenital benign growths are represented by the verrucous and 
vascular nsevi of Pringle and Darier. They increase slowly after 
birth aud attain a notable development at about the period of 
puberty. They also are found about the regions of the face named 
above, including the chin and the mouth. The lesions are pin-head 
to bean-sized, and differ from those above described chiefly in the 
color they present, which varies from a yellowish white to a deep 
brownish-red ; often the surface is vascularized by the presence of 
minute capillaries. They are sometimes discrete, often confluent, 
and may be commingled with comedones, acne pustules, pigmented 
patches, and the lesions of facial seborrhcea. 

The two forms named above are benign lobulated tumors of the 
type of sebaceous adenoma ; the last-named group being distinguished 
by the delicate telangiectases over their surface, and their verrucous 
structure. 

The malignant forms of sebaceous adenomata occur when the skin 
is in the senile state. They begin with the symptoms of an irri- 
table acne or seborrhcea, greasy crusts being displayed here and 
there, particularly over the surface of the iace, or comedones of 
unusual type; or papulo-pustules which do not observe the course 
of those seen in earlier years. Ulceration attacks the lesion which 
at first seemed benign, and the issue is the development of an epithe- 
lioma. 

Adenoma of the Coil-glands occurs in slowly developing 
groups of pallid or normally tinted papules over the scalp, forehead, 
nose, cheeks, and lips, varying in size from a pin-head to a small 
pea. When punctured a droplet of clear fluid escapes, evidently an 
encysted liquid, as no more follows upon pressure. The disorder is 
encountered chiefly among those who at some time or another have 
been subject to exceedingly profuse facial sweating. In some in- 
stances no fluid escapes on puncture, the lesions having been con- 
verted into a empty cyst. 



542 DISEASES OF THE SKIN. 

Perry 1 describes a case illustrated by a chromo- lithograph of a 
woman upon whose face and trunk millet-seed to small pea-sized 
nodules were visible, lasting for nearly twenty years. Upon puncture 
a clear fluid could be expressed from each. On section the coils of 
the sweat-glands were found enormously increased in size, and there 
was pigmentation of the gland cells. 

Certain whitish or yellowish, pin-head-sized, rounded and isolated 
lesions, with gelatinous contents, scattered over the faces of persons 
in middle life and advanced years, are occasionally seen either 
flattened or slightly elevated above the level of the integument. 
They have been described under the title of " colloid degenerations 
of the skin/' but are probably instances of adenoma of small acini of 
the sebaceous glands, the epithelium of which has undergone colloid 
degeneration. According to Heitzmann, the distinguishing feature 
of them all is a wreath of cuboidal or short columnar epithelium, 
inclosing a distinct cavity. Besnier, 2 however, concludes that the 
connective tissue elements of the derma are primarily involved in the 
colloid degeneration, and the glanular epithelia secondarily. 

In general, the features of adenoma are well defined, circumscribed 
tumors, pin-head to small egg-sized and larger, sessile or peduncu- 
lated, softish or quite firm, always occurring in regions where there 
are either coil-glands or sebaceous glands. For a time, after the 
formation of such a tumor, the gland or glands from which it is 
proliferated may discharge the usual function. The course of the 
tumor may be stationary ; it may atrophy ; it may degenerate by an 
ulcerative process ; cysts may form ; or the contracted cells undergo 
hyaline, colloid, or fatty degeneration. 

Sections of simple adenomatous tumors always exhibit the epithe- 
lium of the glandular structure from which the new growth was 
derived, and the connective tissue framework of tumors in gen- 
eral. 

The diagnosis is from epithelioma, molluscum epitheliale, steatoma, 
and lipoma, for the exact determination of which examinations of 
sections with the microscope are needful. 

The treatment, when any is required, is surgical ; and the prog- 
nosis, in uncomplicated adenoma, favorable. 



Colloid Metamorphosis of the Skin. 

(Colloid Milium [of Wagner] ; Colloidome Miliaire [of Besnier] ; 
Hyaloma ; Hyalom der Haut.) 

This is a rare dermatosis which has been confused with the lesions 
of adenoma already described. 3 

Like the minute papules of that affection, it is chiefly seen over 

i Intern. Atlas of Rare Skin Diseases, 1890-91. 

2 Ann. de Derm, et de Syph., t. x., Nov. 5 and 6, 1879. 

* Cf. Besnier ; Gaz. Hebd. de Med. et cie Chir., October 10, 1SS9. 



MYOMA. 543 

the scalp, brow, cheeks, root of the nose, circumorbital regions, neck 
and arms. Pin-head to pea-sized, translucent, whitish or slightly 
yellowish, smooth, roundish papules develop, resembling vesicles of 
similar size. They are usually well embedded in the skin, and on 
puncture give exit to a gelatinous mass, at times accompanied by a 
droplet of blood. They are readily removed with the curette, may 
be surrounded by superficial telangiectases, and may undergo a 
retrograde metamorphosis till the lesion disappears, or be exfoliated, 
or undergo inflammation followed by crusts, after the fall of which a 
persistent mark remains. 

Balzar has shown that the lesions are constituted of colloid masses 
derived originally from cells near the pilo-sebaceous pouches of the 
superior portions of the derma. They are surrounded by connective 
tissue, and probably originate in the vascular plexus of the upper 
corium. 



2. Of Muscular Tissue. 
Myoma. 

Gr., fivuv, muscle. 

Myoma is a tumor of the skin which is composed, in great part, of muscular 
fibres. 

Tumors of the skin composed of smooth muscular fibres are 
known as Myomata, Leiomyomata, or Lyomyomata. But 
little attention had been attracted to these new growths up to a recent 
date. Jullien, 1 however, in a review of the contribution to the subject 
made by Messrs. Brigidi and Marcacci, of Florence, and published by 
them in the Imparziale, in 1881, gives a full capitulation of the 
bibliography of the subject. 2 

From these reported cases it appears that the tumors originate as 
usually single, though occasionally multiple, elevated, disseminated, 
small pin-head to orange-sized, macular or tubercular lesions, the 
skin covering which is smooth, stretched, and glistening, with a rosy 
or dark reddish tint, paling or not under pressure. The developed 
lesions may be sessile or pedunculated, and either intensely painful, 
pruritic, or remarkably sensitive to cold. Under the influence of 
muscular contractions, there may be, as in the cases of Challand and 
Axel-Key, slow vermicular motion and frequent changes of volume 
or other evidences of contractility. They occur either as generalized 
lesions, or limited to the thorax, scrotum, mammae, labia majora, and 
the hands and feet, including the palmar and plantar surfaces. The 

1 Ann. de Derm, et de Syph., t. iii. 2 me ser., Feb. 25, 1882. 

2 1854, Virchow ; 1858, Forster, Verneuil ; 1864, Klob, two observations ; 1871, Cballaud, two 
observations ; 1873, Marcano Sokoloff; 1878, Axel-Key, Santesson ; 1880, Besnier ; 1881, Arnozan 
and Vaillard , Brigidi and Marcacci. 



544 DISEASES OF THE SKIN. 

ages of the patients varied from the twenty-fifth to the sixty-fifth year 
of life. Of thirteen persons whose sex was given, five were males 
and eight females. 

Pathologically, these cases were reported as either pure myomata, 
or highly vascular types of Myoma Telangiectodes and Fibro- 
myoma. Verneuil's case resembled a neuroma, as it contained not 
only smooth and striated muscular elements and bloodvessels, but 
also nerves. The case of Axel-Key is recorded as one of Lymph- 

ANGIECTASIC FlBRO-MYOMA. 

The disease is a benign new growth, and is not to be confounded 
with prurigo, lepra, syphilitic gumma, neuroma, sarcoma, or 
fibroma. 

Babes, more lately, divides these growths into (a) those derived 
from the smooth muscle-fibres of the vessel-wall ; (6) those derived 
from the cutaneous muscular network. 

The first (angiomyomata) are combinations of new growths of vessels 
with muscle-fibres derived from the vascular parieties. The second 
(dartric myomata) are seen especially about the scrotum, labia, and 
mammae. The deep muscular apparatus of the region named (dartos, 
etc.) contributes in these cases the muscular elements of the tumor. 
In still other cases muscular tumors occur when no such tissue 
normally exists. In these cases a deep aponeurosis or subcutaneous 
muscle furnishes the basis of the neoplasm. 

In a case treated by the author, multiple pin-head to large bean- 
sized congenital tumors were situated near the sterno-cleido-mastoid 
muscle of a girl nineteen years old. These were exquistely sensitive 
to pressure, were capable of slight vermiform motion when irritated, 
and examination of the largest, after removal, exhibited smooth 
muscular fibres, and, in small proportion, terminal filaments of 
cutaneous nerves. 

The course of the disease is slow, lasting as it may for several 
decades. The etiology is unknown. Treatment is by enucleation ; 
or removal by ligature, electrolysis, or incision. 



3. Of Vessels. 
Angioma. 

Gr., ayyelovj vessel. 

Angioma is that pathological development which is constituted wholly or in part 
of dilated or new-formed blood- or lymph-vessels. 

The angiomata are naturally divided into those composed of blood- 
vessels and those formed of lymphatic vessels. The former are much 
more frequent and variable in character. 

Blood- vascular new-growths occur in three forms : nsevus vascu- 
losus, telangiectasis, and angioma cavernosum. 






ANGIOMA. 545 

Naevus Vasculosus. 
(Naevus Flammeus ; Naevus Sanguineus. Ger., Gefassmal.) 

This term is limited to those vascular anomalies of the skin which 
are either visible at birth or become developed in a brief period there- 
after. They commonly occur as irregularly outlined or distinctly 
circumscribed, smooth spots, patches, or maculations, varying in color 
from light red to deep violet and port-wine, either flat or very slightly 
elevated above the general level of the integument. From this type 
wide variations are noted, from the development of pea-sized papules 
or tubercles, to tumors even of large size ; pulsating and aneurismal 
in character ; spongy or relatively firm ; fading or more rarely per- 
sistent under pressure ; superficial or deeply seated ; venous or arterial 
in their connections ; single or numerous ; and in either case limited 
to a small area or involving a relatively large surface. They are of 
most common occurrence upon the head, but are seen also on the 
trunk aud extremities. Often they are the sole lesions of the skin 
present in a single individual ; in other rarer cases they complicate 
moles, warts, and lymphangiomata. 

The surface of these lesions is usually smooth, though it may be 
rugous. They are generally compressible, losing their habitual color 
when the blood is forcibly pressed out from the loose mesh-work of 
vessels of which they are composed, and becoming turgid and deeply 
tinted when the blood is forcibly driven into their tissue, as in the act 
of sneezing. 

The course of these lesions varies with their essential character. 
Of the simpler varieties, the larger number increase somewhat in 
extent and development till they have attained a maximum size, and 
then either persist indefinitely or accomplish a species of involution 
after agglutination of the vascular walls, leaving a whitish, cicatri- 
form, occasionally pigmented surface. Others extend indefinitely, 
involving the neighboring mucous surfaces, subcutaneous tissue, and 
deeper structures, forming vast tumors, destructive not only by their 
tendency to extension, but by their mechanical effect. Fortunately, 
these extreme developments are rare. Much more commonly they 
are observed in the forms known as the " port-wine mark " or " claret- 
stain/' which awaken no subjective sensations, and are usually of 
clinical importance in consequence of the marked disfigurement which 
they occasion. 

Occasionally, especially in the case of infants but a few days old, 
phagedena or gangrene will suddenly occur in these patches without 
appreciable cause (probably in consequence of the occurrence of 
thrombus), and the entire tumor will be removed, the line of demar- 
cation of the destructive process being exactly limited to the border 
of the angiomatous tissue. The scar resulting is superficial, and 
becomes smoother in course of time. In this way the author has seen 
spontaneous cure of nsevi of considerable size existing on the head and 
genitalia of infants. 

35 



546 DISEASES OF THE SKIN. 

Telangiectasis. 
(Nsevus Araneus; Spider Cancer.) 

Telangiectases are acquired blood-vascular new formations, which 
appear at periods of life other than at birth or a few months later ; 
and are, therefore, distinct from the congenital forms of the disease. 
They are commonly first observed in adult life, and occasionally 
multiply with advancing years. They occur in diffuse and localized 
forms. 

Diffuse, generalized telangiectasis is exceedingly rare. Hillairet 
and Yidal have each observed one such case in individuals of 
both sexes ; the condition being apparently due to systemic dis- 
turbance. 

The localized forms are betrayed by the occurrence of flat or 
slightly elevated, pin-head to pea-sized maculae ; diffuse patches ; 
linear ramifications of individual vessels; or coutorted congeries of a 
plexus of the latter, all exhibiting the variations in color of nsevi 
vasculosi, but usually of pinkish or violaceous hue. They are 
unaccompanied by subjective sensations, are evidently non-inflamma- 
tory in character, aud are seen as single or multiple lesions chiefly 
upon the face, but also upon the neck, the back of the hands, the 
thighs, and other parts of the body. They are not rarely observed in 
connection with other diseases. Thus they occur in the vicinity of 
the lesions of lupus erythematosus, scleroderma, acne rosacea, cica- 
trices, and about the contour, or over the surface of many malignant 
tumors. They may, therefore, have either an idiopathic or sympto- 
matic character. 

The term Rosacea, as distinguished from acne rosacea, is em- 
ployed to designate that condition in which the skin, of the face 
particularly, exhibits a circumscribed or diffuse redness, due to dila- 
tation of the capillaries, unassociated with acne or other sebaceous 
gland disorder. (The reader is advised to consult the chapter on 
acne rosacea.) 

The conditions here described as nsevus vasculosus and telangiec- 
tasis are displayed in forms which, apart from the question of con- 
genital origin, offer the widest difference and the most bizarre 
combinations. The so called nsevus flammeus, nsevus araneus (spider 
cancer), nsevus vinosus, " mulberry," " strawberry," and " mother's 
marks " are all examples of these combinations. 

The lesions are often congenital. There is not sufficient proof that 
they are due to ante-natal maternal impressions. The influence of 
the nervous system in deciding the area of limitation of the con- 
genital forms is exceedingly distinct, as, for example, the definition 
of a port-wine mark in the skin area supplied by one supra-orbital 
nerve. 

Pathology. — Billroth states that the new formation has its origin 



ANGIOMA. 547 

in the vascular network surrounding in basket-like forms the fat 
lobules, follicles, and glands of the skin. Embryonal, vascular 
growths spring from these, and as they multiply and develop are 
enforced by proliferation of fibrous, connective, and muscular tissue. 
The color depends largely upon the preponderance of arterial or of 
venous capillaries in the new formation. 

Diagnosis. — The ordinary lesions of angioma are readily recognized 
by their color, size, shape, and obvious vascular constituents. An- 
derson calls attention to the importance of differentiating encephalocele 
due to the failure of ossification of the ethmoid and frontal bones at 
the root of the nose. Operations upon such tumors, when supposed 
to be angiomatous in character have resulted fatally. Lobulation, 
great distention (when a child is crying), a superficial rather than 
deep and complete vascularization of the smooth and glossy skin of 
the tumor, and a double pulsation in it, all point to frontal ence- 
phalocele. 

Treatment. — The treatment of all forms of angioma is described in 
detail in the chapter on angioma cavernosum, The best method is 
decidedly that by electrolysis when it is practicable. Then may be 
named excision ; amputation ; injection of pure carbolic acid, tannic 
acid, or the perchloride of iron; ligature of vessels; vaccination; 
ligation of tumors producing strangulation , the actual cautery ; the 
galvanic ecraseur ; the use of the seton ; and the application of such 
caustics as the ethylate of sodium. Squire's method of multiple 
puncture and scarification has at times failed in the author's hands to 
accomplish the desired end. 

Angioma Cavernosum. 
(Tumor Cavernosus.) 

It is distinguished from the other angiomatous lesions described 
above by the peculiarities of its formation. It consists of a dense 
framework of new-formed connective tissue, inclosing loculi or cham- 
bers of varying capacity, containing blood, and communicating not 
only with each other, but with the larger vessels in the vicinity. 
Whether they originate in the fibrous felt- work of the derma, which 
later establishes a vascular connection, or in the vessels themselves, 
or are constituted by a mechanical dilatation of the latter, in conse- 
quence of new-formed connective tissue in the adventitia, has not 
been determined. According to Virchow, they arise generally from 
coalescence and dilatation of vessels. Other causes are explained by 
the earlier formation of a contracted cicatricial tissue by which vas- 
cular distortion occurs. (Rindfleisch.) 

They are said to be rarely congenital, developing soon after birth, 
and to be both superficial, deep, circumscribed, and diffuse. Some- 
times they originate from a nsevus or superficial telangiectasis. Often 
when fully formed, they are distinctly encapsulated. The diagnosis 



548 DISEASES OF THE SKIN. 

is between cysts, fibromata, lipomata, and sarcomata. Their rarity 
in dermatological practice may be explained by the surgical features 
of many cases. In five years, no instance of angioma cavernosum 
was reported in the statistical tables of the American Dermatological 
Association. 

Etiology and Pathology. — The causes of the several forms of angioma 
named above are obscure. The symptomatic telangiectases are 
undoubtedly to be explained by obstruction to the circulation occa- 
sioned by the tumor or other lesions to which they are accessory. 
The foundation for the vulgar belief that maternal impressions are 
responsible for the so-called " mother's marks " is very slight. The 
reputed resemblance of the latter to various flowers and fruits gener- 
ally requires for its recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation and 
formation of venous and arterial capillaries in the superior portions 
of the derma, the vessels of the newly formed plexus freely com- 
municating with each other. Generally there is a simultaneous new 
formation of connective tissue constituting the framework of the 
growth, which varies considerably in the different forms of the dis- 
ease. Lobules constituted of coils of capillary vessels are often 
separated by it into distinct masses. According to Heitzmann, the 
large spaces of angioma cavernosum imitate the structure of the 
corpora cavernosa of the penis, and are filled with venous blood, 
being separated from each other by a scanty fibrous connective 
tissue. 

Treatment. — The treatment of this group of new growths is, in 
general, limited to a series of local surgical procedures. These all 
have in view either the destruction of the new growth, or the arti- 
ficial production of an inflammation, in order to obliterate the lumen 
of the capillaries of which it is composed, to an extent sufficient to 
interfere with the transmission of the blood-current. 

First among these is electrolysis. One or a set of several fine 
cambric needles, with their points at the same plane, are connected 
with the negative pole of an ordinary zinc and carbon battery of ten 
to twelve cells. The points of the needles are quickly passed into 
the tissues, and there held for a period of between ten to thirty 
seconds, according to the effect produced after completion of the 
circuit, with a current of from one to two milliamperes. The new 
growth is thus blanched in the vicinity of the needles, this effect 
disappearing in the course of a few moments. In about three 
weeks the curative result of the operation becomes apparent. Ac- 
cording to Fox, 1 of New York, the objections are that the operation 
is sometimes painful and tedious, and may occasionally result in the 
production of suppuration, superficial sloughs, minute, keloid-like 
elevations, vascular nodules, depressed scars, or superficial ulcers. 
The author has operated in scores of cases without the production of 

i New York Med. Record, Feb. 18, 1882, p. 1S8. 



ANGIOMA. 549 

any results worse than the original disfigurement, usually with com- 
plete success. 

The method of Sherwell 1 is by multiple puncture with a set of 
fine needles in a holder similar to that described above. These are 
dipped in a twenty-five to fifty per cent, solution of chromic acid, 
and then made to penetrate the part to be attacked. The bleeding 
is readily arrested by pressure, and then the patch is to be covered 
with several superimposed layers of flexible collodion. This pro- 
cedure is of value in circumscribed patches of superficial character 
and relatively limited area. By it the author has succeeded in re- 
moving port-wine marks in three patients, with the result of pro- 
ducing a somewhat irregular cicatriform tissue much less disfiguring 
than the original blemish. One of these patients was repeatedly 
exhibited at the clinic during the progress of the case. 

Squire's operation is done upon previously frozen patches by the 
aid of an instrument which destroys the vessels by making numerous 
crossed and closely spaced linear incisions, parallel to each other and 
in a plane obliquely directed to that of the integument. Here also 
bleeding is arrested by pressure, exerted before the circulation is re- 
stored. The operation has been, in hands other than his own, at- 
tended at times with unsatisfactory results. 

Sodium ethyl ate, a compound in which the radical ethyl in ethyl ic 
alcohol is united with sodium, is a caustic recommended by Richard- 
son 2 in the treatment of naevus. It is applied by means of a glass 
rod. A first application usually results in the formation of a dense 
crust under which the nsevus contracts, and repeated applications are 
made at intervals of a few days till the desired result is obtained. 
The sodium ethylate should be pure, and the crusts should not be 
disturbed till they fall spontaneously. In one case observed by the 
author, there was a persistent redness of the resulting scar which 
was decidedly open to objection. 

Other methods employed are the ligature when practicable ; punc- 
ture with hot needles ; the topical application of caustics other than 
those named above, such as hydrate of potassium, nitric and carbolic 
acids, and corrosive sublimate, and total excision, the latter being 
practicable in relatively small growths. Larger growths can now 
also be removed and the surface covered with skin grafts. The 
galvano-cautery and the thermo-cautery are both valuable in the 
destruction of the capillaries, and have repeatedly proved successful 
in my hands. For telangiectases and naavi no larger than a pea, the 
Paquelin knife is an efficient resort. The old method of multiple 
vaccination about and upon the involved area is frequently followed 
by the best of results, and whether in consequence of the retraction 
of tissue under the influence of the inflammation excited, or of the 
destructive results of the suppuration induced, or of an indefinite 
caustic effect, is not, as Kaposi suggests, quite clear. 

These results may be partly imitated by the induction of superfi- 

1 Archives of Derm., Oct., 1879. - Lancet, November 9, 1878. 



550 DISEASES OF THE SKIN. 

cial pustulation and suppuration through the medium of tartar emetic 
and croton oil, methods which certainly should be considered clumsy 
in the light of recent successes obtained by more manageable expe- 
dients. 

Injections with carbolic acid and the perchloride of iron, though 
in a few cases followed by fatal results, are at times successful. 

Coombs 1 has lately modified somewhat the method most in vogue, 
by passing fine silver wires through nsevous growths, and connecting 
the extremities with a Bunsen's battery. When the wires are heated 
the circuit is broken, and the ends of the wires disconnected from 
the battery and united to each other, being left in situ and covered 
with lint and plaster. The current can then be passed repeatedly 
without reinsertion of the needles, and the latter need be withdrawn 
only when the cure is complete. 

The Treatment of angioma cavernosum requires surgical interfer- 
ence. 

The Prognosis in any case of angioma rests upon the method of 
treatment adopted for its removal. In the larger number of cases, 
the lesions having attained a maximum development, persist without 
further pathological change, constituting a deformity rather than a 
disease. Physiological alterations in the color of such lesions occur 
under the influence of changes in the circulation. 

Angioma Serpiginosum. — (Infective Angioma ; Nsevus Lupus). 
Under these titles Hutchinson, 2 Jamieson, Lassar, and Tay describe 
a condition in which minute bright reddish puncta, resembling grains 
of cayenne pepper, form peripherally-spreading groups, which ex- 
hibit clearing centres and thus produce annular lesions, a centimetre 
or more in diameter. Larger areas of involvement can be subse- 
quently seen with gyrate borders and occasionally outlying dots or 
points, which Hutchinson describes as " infective satellites." The 
puncta vary from vivid to a purplish red ; at first disappearing on 
pressure, later persisting. The parts chiefly affected are the arm, 
forearm, shoulder, wrist, hands, and fingers. A few groups have 
been distinguished over the ears, cheeks, chest, and lower extremities. 
The disease has a period of slow evolution with accesses of advance. 

But four cases are recorded, three girls ; one occurring after vio- 
lent exertion ; one as a sequel to a port-wine mark ; one after con- 
vulsions. 

The disorder seems to be simply a clinical phase of telangiectases. 

i London Lancet, 1881. 2 Archiv. of Surg., 1891. 



LYMPHANGIOMA. 551 

Lymphangiectasis Cutis ; Lymphangioma. 

Lympha, lymph ; ayyelov, a vessel ; eicraoig, dilatation. 

(Lymphangiectodes. Fr., Varices Lymphatiques Dermiques ; 
Dermato-lymphangioma.) 

Lymphangiectases and Lymphangiomata of the skin are neoplasms of the lym- 
phatic system often commingled with new growths of connective and other 
tissue. 

Lymphangiectasis is a rare disorder characterized by the occur- 
rence, within and beneath the skin, of lesions resembling vesicles, 
grouped or irregularly arranged over the surface, with and without 
intervening healthy integument which are connected anatomically 
with the lymph vessels and are usually distended with lymph. They 
are really lymphatic varices, either simple or parasitic, and due to 
the presence of filaria in the vessels. They occur about the face, 
shoulders, over the trunk, and on the extremities, where they vary in 
size from a pin-head to a small pea, and may coutain either a trans- 
lucent or yellowish or even reddish fluid. Their walls are quite 
thick; and the lesions themselves frequently resemble in appearance 
verrucous growths. They are often interspersed with telangiectases, 
but even though having a reddish hue, are never inflammatory in 
type. They may last for years and may complicate other disorders. 
When blood-vascular growths are actually commingled with the tis- 
sue of which they are composed, the compound lesions are termed 
hsematangiomata. 

When these dilated vessels are ruptured by accident or otherwise, 
a continuous or intermittent flow of lymph ensues, which in some 
cases may prove to be of the gravest injury to the system, and may 
result in the production of lymphatic fistula?. 

Variations occur in the direction of isolated or agglomerated linear 
or ribbon-like varices of the lymphatics, perceptible by palpation 
beneath the epidermis. The disease occurs chiefly in males, usually 
beginning in childhood and is due to obscure causes. These are at- 
tributed by some authors to inherited predisposition. Both an acute 
and chronic form have been described, the latter due to the external 
influences of the trades and the traumatisms incidental to manual 
work. In some cases the disease has been recognized in association 
with tuberculosis, syphilis, " scrofula," and carcinoma. 

The Treatment is by chemical destruction or surgical ablation of 
the new-formed vessels ; but the results are not to be depended upon, 
as recurrence is the rule. Electrolysis has been, in a few cases, em- 
ployed with success. 

The Prognosis is doubtful in most cases, and in some may be 
grave. 



552 DISEASES OF THE SKIN. 



Lymphangioma (Circumscribed Lymphangioma). 

Two varieties of these growths are recognized, the simple, and the 
cavernous. 

The simple forms may occur in any portion of the skin as cir- 
cumscribed enlargements, often of congenital origin. The thickened 
part is made up of connective tissue and in places of lymphan- 
giectases of the sort described above. These are recognized as con- 
taining lymph. Tumors of this order are usually of mixed type, 
including not merely connective but also fibrous and even fatty 
tissue. These are chiefly surgical affections. 

Cavernous lymphangioma is a term representing the rare forms of 
disease illustrated by the case of Morris. {International Atlas of 
Rare Skin Diseases, 1889, No. 1.) In this case clusters of wart- 
like vesicles occurred over the left trapezius containing a clear 
albuminoid fluid, with tufts of injected blood capillaries upon and 
between their apices. According to Besnier and Doyon, who have 
carefully studied these cases, the disease is really a circumscribed 
lymphangioderma developed upon a vascular nsevus resting upon a 
thickening of the skin, and occurring only after a series of febrile 
phenomena precisely as in elephantiasis. 

Lymphangioma Tuberosum Multiplex. — These rare growths 
of lymphatic vessels in the skin have been noted by Hebra and Kaposi, 
Pospelow, 1 Van Harlingen, 2 and a few other writers. The lesions in 
these several cases were multiple, pea- to bean-sized, smooth, roundish, 
reddish, lilac-tinted or bluish, firm or compressible tubercles, im- 
planted in the skin, and occurring first in early life, about the neck 
and trunk. Some of these were quite reducible under pressure, and 
transparent. In Van Harlingen's case, the lesions were destitute of 
fluid contents, and also interspersed between telangiectases. Anat- 
omically, roundish or oval spaces appeared in sections, recognizable 
as distended lymphatic vessels by the characteristic endothelium with 
which they were lined. Kaposi distinguishes these tubercles from all 
subcutaneous cavernous tumors constituted of new-formed dilated 
lymphatic vessels reaching toward the skin, by the limitation in the 
former of the neoplastic growth to the superior parts of the corium. 

In comparing these with the large number of cases of congenital 
and acquired dilatation of the lymph channels, collated in the valu- 
able monographs on these subjects by Dr. S. C. Busey, 3 of Washing- 
ton, D. C, a further special difference between the two becomes ap- 
parent. In the latter, when the lymph-filled vesicle, papule, or 
tubercle, which appears upon the integument is ruptured, there at 

i Viertelj.f. Derm. u. Syph., Hft. 4, 1879. 

2 Paper read before tbe Amer. Dermat. Association, September, 1881. Phila. Med. Times,. 
September 24, 1881. 

3 Congenital Occlusion and Dilatation of tbe Lymph Channels (Amer. Journal of Obstetrics, 
January, 1877, et seq.) ; Narrowing, Occlusion, and Dilatation of Lymph Channels, Acquired 
Forms (New Orleans Medical and Surgical Journal, No. 3, 1876, to No. 8, 1878, inclusive). See, 
e.g., history of Berkley Hill's patient, p. 101; of Zambuco's, p. 120; of Carter's, p. 103; of 
Cholmley's, p. 136 ; of Jackson's, p. 173, and many others. 



ANGIOMA PIGMENTOSUM ET ATROPHICUM. 558 

once supervenes an exhausting drain from the body, of pure, coagu- 
lable lymph, a feature which is not described by the dermatological 
authors named, as of occurrence in their cases. 

Most of the diffuse forms of lymphangioma, those of the class last 
described, constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymphangiectatica or Pachydermia Lymphangiectatica. 
These contain often large lymph-filled sacs or lacunae, enveloped in 
hypertrophied muscular and connective tissue, and an cedematous 
integument. Some of the elephantiasic deformities of this character 
are fully as enormous as the extreme distortions of elephantiasis 
proper. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions, where the lymphatic vessels in the 
lymphatic glauds dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
elsewhere described. 

Lymphangiomata may be congenital or appear soon after birth. 
Their cause is unknown. Anatomically the lesions are found to 
consist of greatly developed lymphatic vessels, lined with endothelium 
and enveloped in small-celled connective-tissue stroma. The treat- 
ment, of the larger lesions only, is surgical. 



Angioma Pigmentosum et Atrophicum. 

(Xeroderma Pigmentosum ; Dermatosis Kaposi ; Melanosis Lenticu- 
laris Progressiva ; Liodermia cum Melanosi et Telangiectasia.) 

Few cases of this disease have been recorded ; and these by 
Kaposi, Glax, Crocker, Vidal, Pick, Neisser, and Geber, abroad ; 
and, in this country, by Taylor, of New York, in an interesting 
series of seven cases ; by Duhring, of Philadelphia ; by White, of 
Boston, and others. The disease results ultimately in a diffuse idio- 
pathic cutaneous atrophy, but this condition is preceded by a general 
hyperseniia with vascular dilatation ; the production of numerous, 
punctiform, bright red, pin's-head to pea-sized, flat, or raised telangi- 
ectases ; and disseminated, brownish, and yellowish-brown macula?, 
varying in extent ; between which form superficial, whitish and 
glossy, atrophic depressions, like the cicatrices of variola. The 
melanosis is at times so uniform and diffuse as to suggest the dark 
tints of the Spanish skin, as in Prof. White's case, with a dense 
spattering of a still darker hue and a blackish scrotum. The 
atrophic or leucodermic condition of the skin may coexist with the 
melanoderma, and present large well-defined areas totally devoid of 
pigment where the skin may have a pinkish tint. The ears may 
thus come to resemble tanned sheep-skin. Prof. White in the case 
under his observation could trace no transformation from a pigment 
macule into a telangiectasic lesion. The skin soon becomes furrowed, 
contracted, and as dry as parchment; and thus is readily developed 



554 DISEASES OF THE SKIN. 

an eczema or a superficial degeneration, including ulceration. A 
species of furfuraceous desquamation also occurs in patches. The 
faces of most patients exhibit a peculiar checkered appearance, from 
the uniform dissemination over the skin of the pigmented maculae. 
Ectropion, with ulcerative keratitis, epitheliomatous, sarco-carcinoma- 
tous and angio-myxomatous growths complicated several of the cases 
reported ; and in two, certainly, were the immediate causes of a fatal 
issue. Often, however, the general health seems, for long periods of 
time, to remain unimpaired, the subjective sensations being slight. 
Observers of these cases differ somewhat as to the order in which the 
several lesions of the disease appear ; and Duhring thinks it possible 
that no definite order is observed in the evolution of the symptoms. 
Both sexes in early life seem equally predisposed to this disease, 
though the large number of members of single families affected with 
its symptoms indicates the importance of predisposition and heredity 
in point of etiology. It is usually first manifested before the third 
year of life. 

In 1889 the author had the opportunity of examining two patients 
affected with this disease, presented by Quinquaud to the Interna- 
tional Congress of Syphilography and Dermatology in Paris. Since 
then a number of cases, one in this country, about sixty in all, have 
been recorded. 

The regions involved are, as a rule, the exposed surfaces, viz., the 
face, ears, neck, shoulders and chest to the third ribs, and even to the 
lumbar region, the arms aud back of the hands, occasionally the legs 
and the dorsum of the feet. The yellowish-brown, freckle-like spots 
are soon after their appearance intermingled with superficial cicatri- 
form depressions, either unnaturally whitish in hue or of the color of 
the normal skin. The punctiform or linear dilatations of vessels, 
usually numerous, furnish a striking contrast with the freckled and 
pigmented parts. In some parts the skin is seen to be of a parch- 
ment-like thinness ; in others it is furrowed, laminated, and split, as 
if too dry or too brittle. It is usually deprived of its normal sup- 
pleness ; is retracted ; often attached to the subdermic tissue. 

The disease commonly begins in the first or second year of life, 
and progresses continually. The order of occurrence of the lesions 
as given by Kaposi, is first, the vascularization and pigmentations ; 
then disappearance of the telangiectases, and occurrence of the cica- 
triform depressions ; finally a diffuse atrophy of the skin. 

The eczemas of the face, superficial ulcerations, and ocular changes 
(pterygium ; ciliary blepharitis ; telangiectases of conjunctivae) are 
all secondary to the general conditions described above. 

In the course of years the verrucous growths appear, starting 
usually in the pigmented spots, either epitheliomatous, sarcomatous, 
or angiomatous in character. They may be single or many ; may be 
confined to the skin or develop in the viscera ; and usually lead to 
fatal results in a few or many years. 

Pathology. — The disease begins as a proliferation of connective 
tissue in the papillary layer, with involvement also of the vascular 



ANGIOMA PIGMENTOSUM ET ATROPHICUM. 555 

endothelium, followed in some points by retraction and in others by 
both ectasis and new formation of vessels. By Kaposi, who has the 
honor of first naming and describing the disease, the irregular accu- 
mulation of pigment is regarded as consecutive to the vascular 
changes. The rete pegs extend deeply below ; there is ectasis of the 
glands and epithelial degeneration. 

With the French the disease is generally regarded as a pigmentary 
epithelioma or " epitheliomatous lentigo " (Quinquaud), the connection 
between the neoplasm and the pigment anomaly being regarded as 
similar to that recognized in melanotic sarcoma. 

The Etiology of the disorder is exceedingly obscure. A congenital 
predisposition is shown by the occurrence of several cases in one 
family ; most of the patients have been females. There is a very 
singular disposition of the disease to select one sex in different 
families. In forty- three cases collated by Kaposi, there were six 
times, two ; four times, three ; and once, seven brothers or sisters 
affected with the disease. The age of the patients first exhibiting 
the disorder is from the first to the second year. Schwimmer has 
reported one case occurring in the thirty-fifth year. Unna believes 
it possible that the action of light upon the skin has an influence in 
the production of the disease. 

The Diagnosis is chiefly from scleroderma, but as the latter always 
begins with induration of tissue ; and as angioma pigmentosum et 
atrophicum always begins with either erythematous or pigmented 
spots, the distinction is clear. In the case of scleroderma too, apart 
from its onset at a later period of life, the pigmentations are late 
rather than early ; and the telangiectases are found in circumscribed 
scleroderma as a violet-tinted border about a patch ; never as points, 
nodules, aud stellate markings, interspersed among pigmented spots 
and depressions. Lepra maculosa is characterized by marked anaes- 
thesia in and about the pigmented and non-pigmented areas ; further, 
its course is toward mutilations of the body, and even at an early 
period there may be vesiculation. 

The Treatment of the disease is limited to amelioration of the con- 
dition of the skin as indications arise. Chrysarobin, resorcin, pyro- 
gallic acid, aristol, and surgical ablation of tumors with electrolysis 
have all been employed. 

The Prognosis is in the highest degree unfavorable, as most of the 
patients succumb to marasmus in from ten to twenty years. 



556 DISEASES OF THE SKIN. 

4. 

Rhinoscleroma. 

Gr., pig, or piv, the nose ; and OKkrjpdg, hard. 

Rhinoscleroma is an infectious granuloma affecting the skin and mucous mem- 
branes of the nose and other organs, characterized by the formation of exceed- 
ingly dense, elastic, and painful, flattened or elevated plaques, nodules, or 
tubercles, which may be isolated or confluent. 

Symptoms. — A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, 1 has been obtained from a study of some 
one hundred eases observed by these and other authors. The follow- 
ing is a concise description of the malady as thus presented. 

The disease commonly begins in the septum or a single ala of the 
nose, without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 
are flat patches, or elevated and circumscribed nodules, papules, and 
tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or a 
light or dark red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses, 
the alse become enlarged, flattened, and so indurated that they cannot 
be pressed together, while respiration may be impeded by stenosis of 
the nares. The process may extend to the neighboring parts, 
involving thus the upper and lower lips, gums, velum 5 epiglottis, 
larynx, trachea, and jaws, the teeth meanwhile falling from their 
sockets and the soft palate becoming in some cases perforated. Invo- 
lution of the process has not been observed, as the lesions do not 
degenerate by ulceration. Max Zeissl, 2 however, reports a single 
case in which there had been ulcerative destruction of the entire left 
nostril, as well as the tip and right ala of the nose. Occasionally 
superficial excoriations have occurred, but very rarely a diminution 
in the consistency of the mass. The disease is exceedingly chronic, 
requiring years for its development ; and though the affected parts 
are painful on pressure, they are otherwise not the seat of subjective 
sensation. 

Etiology and Pathology. — The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and 
individuals of both sexes, free from syphilitic, strumous, tubercular, 
and other cachexia?. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium and its papillary layers, with small, 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to the small-celled sarcoma, inasmuch 
as Mikulicz, Geber, and Billroth have seen some of the elements of 

i Brit. Med. Journ., May 29, 1886. - Wion. med. Wocb., 1880, p. 621. 



RHINOSCLEROMA. 557 

the neoplasm transformed into osseous formations sufficiently common 
in sarcomatous tumors. 

In 1882, however, A. v. Frisch, after examining tissue removed 
from lesions of rhinoscleroma in twelve patients, found in the cells 
and between them in the interpapillary fissures of the connective 
tissue, bacteria distinctly rod-shaped, one and one-half times longer 
than they were broad. These germs were successfully cultivated, 
but experimental inoculations with culture fluids thus obtained were 
negative in results. Neisser in a single case found no bacteria; nor 
did Davis have better success in studying sections removed from his 
patient, the first reported as occurring in Egypt. 1 

Dreschfield, 2 however, found in sections of tissue obtained from 
•Payne's patient numerous bacilli less slender and smaller than those 
occurring in tuberculosis with slightly thickened extremities. These 
were unlike those exhibited by Paltauf, at the Berlin Congress, who 
regarded them as similar to if not identical with Friedlauder's pneu- 
mococcus. Barduzzi, Pellizari, Cornil, Alvarez, Lustgarten, and 
others have added to the evidence in favor of the parasitic nature of 
the disease. 

The bacilli are found encapsulated in a colloid-like substance and 
in series of twos and fours. They occur in the lymphatic ganglia, 
in the giant cells of the neoplasm, and in protoplasmic masses cor- 
responding to these or to their degenerate nuclei. The process of 
phagocytosis has been determined after injections of cultures of 
bacilli obtained from the juice of rhinoscleroma. Pawlowsky, of 
Kieff, in 1890, in this way demonstrated that the bacilli of the 
disease are pathogenic for the lower animals. Besnier and Doyon, 
however, pointing to the limitation of the disease to Austria, reject 
a parasitic origin for the disease. 

Diagnosis. — The disease can hardly be mistaken for another in 
consequence of its situation, the disfigurement it occasions, the ivory- 
like elasticity and induration of the affected parts, and the rarity of 
ulcerative degeneration. As distinguished from syphilis, it is known 
to be entirely unaffected by specific medication. Since rhinoscleroma 
has, however, been by some writers assumed to be a form of syphilis, 
it is needful to clearly distinguish between the two. But, as in the 
former affection there is very rarely any softening of the ivory-like 
induration, much less ulceration which is so common in syphilitic 
gummata, the distinction is tolerably clear. From the variety of 
acne rosacea of the nose, known as rhinophyma, it is readily dfferen- 
tiated by the softness and compressibility of the latter, and its evi- 
dent vascular and glandular composition. 

The ulcerations of epithelioma have a more circular outline, a 
more elevated edge, and occur in persons of a more advanced age. 
Keloid, if found in the situation of rhinoscleroma, does not ulcerate. 

Treatment. — The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 

i Brit. Med. Journ., May 29, 1886. 2 ibid., October 24, 1885. 



558 DISEASES OF THE SKIN. 

the nares by means of laminaria and compressed sponge, where there 
is actual or threatened nasal occlusion. Both excision by the knife 
and destruction by caustics have, however, been found to secure 
merely temporary benefit, as the growth is reproduced with some 
rapidity. 

Prognosis. — The future of the patient is grave. The disease not 
only persists and recurs after operative interference, but may endanger 
life by obstruction of the nostrils. Zeissl's case proved fatal in ten 
years after the disease first appeared. 



Tuberculosis Cutis. 

Cutaneous tuberculosis is declared in the occurrence of numerous and differing 
lesions, characterized by inflammatory, plastic, or retrogressive changes in the 
skin and subcutaneous tissues, due to infection by the bacillus tuberculosis. 

Tuberculosis is one of the most common, formidable, and destruc- 
tive of the great scourges of the human family. It may attack either 
primarily or secondarily any organ or tissue of the body. The skin 
is not rarely the seat of its ravages and when gravely involved the 
results are in the highest degree disfiguring and repulsive. 

The consequences of tuberculous invasion of the skin are usually 
declared early in life, because in those periods the skin is most easily 
invaded, and also because at these ages the habits and environments 
of the individual are conducive to the occurrence of the accident. 
Tuberculosis of the skin may be the result of general infection in the 
body ; or may, on the other hand, be the starting point of such 
infection. In either event the disease is always originally acquired 
by infection and not by inheritance. Children are not born tuber- 
culous. The coincidence of several members of one family exhib- 
iting evidences of the disease is most readily explicable by the 
opportunities for infective accidents furnished in such families. 

In the pages which follow no attempt is made to revert to the 
remarkable and instructive history of the gradual acquisitions of 
science on the subject of this disease. Neither within these limits is 
it desirable to indicate the several conditions which in their relations 
to this subject have been confused in the past, and whose names have 
served as titles for chapters on cutaneous disorders. It will be suf- 
ficient if the results obtained from the vast and valuable labors of 
the pathologists and clinicians of the last decade be concisely set 
forth with a view to the simplest systematic conception of the subject. 1 

Tuberculosis of the skin is conveniently studied in its several 
forms of (1) lupus vulgaris ; (2) tuberculosis verrucosa ; (3) tuber- 
culosis cutis orificialis ; (4) scrofuloderma. 

1 In the preparation of this chapter the author has derived valuable aid from a sympo- 
sium on the subject prepared at the request of the Council of the American Dermatological 
Association, by Drs. James C White, of Boston ; John T. Bowen, of Boston ; and George 
Henry Fox, of New York. Boston, 1892. 



LUPUS VULGARIS. 559 

1. Lupus Vulgaris. 

Lat, Ivpus:, a wolf. 

Statistical frequency in America : 0.433. 

Lupus vulgaris is a tuberculosis of the skin and mucous membranes manifested 
in the production of cutaneous lesions which by resorption, metamorphosis, or 
ulceration, may be productive of grave local injury, and, in cases, be the 
point of origin of generalized tuberculosis. 

Symptoms. — The symptoms of lupus vulgaris are both numerous 
and diverse, a fact which may account for the many names which 
have been applied to its different manifestations, and which with few 
exceptions are descriptive merely of certain external features. 

The lupous infiltrate maybe limited to small areas or diffused over 
an entire region of the body. It may be first apparent in pin-head 
to bean- sized flattened maculations (Lupus Maculosus, Lupus 

Fig. 66. 




Lupus vulgaris of the face (from a photograph of one of the author's patients.) 

Planus), from which may be later developed papules, tubercles, 
nodules of equal or somewhat greater size, rising above the general 
level of the skin and often perceptible within its mass by palpation. 
(Lupus Eodosus ; Lupus Tuberculatus, Elevatus, Tumidus, 

NON-EXEDENS, NON-ULCEROSUS.) 

It is to be noted that as in syphilis, in whose course though almost 
every one of the elementary lesions of the skin may be developed, 
there is a distinct predominance of the papule and tubercle, so in 
lupus vulgaris, the type of the disorder is certainly shown in the 
lupous nodule, the " lupoma" as it is by some authors designated. 



560 DISEASES OF THE SKIN. 

This dull reddish, purplish -shaded lesion, scarcely as large as half a 
pea, maybe the predominant symptom of a lupous patch for a period 
of from ten to twenty years and even more. It is of softish, almost 
boggy consistency, yielding when pressed upon firmly with a blunt 
pointed instrument and readily penetrated by a sharper instrument. 
The English compare its contents with apple-jelly. 

The changes within, about, and beneath these lesions furnish 
practically the clinical pictures of lupus vulgaris. Thus there may 
be extensive oedema, thickening, hypertrophy, hyperplasia (" bouf- 
jissure" pachydermia) even telangiectasis, and an accompanying lym- 
phangitis or lymphadenitis (Lichen Hypertrophicus, Papillo- 
sus, QEdematosus, Elephantiaticus, Tumidus, Exuberans, 
etc.). In many of these cases the prominent symptom which has sug- 
gested these names to the older writers, is in fact a simple inflamma- 
tory swelling, due only indirectly to the lupoid involvement of the 
skin, a fact which can be recognized after any efficient treatment of 
an extensive plaque of lupus of the face, the subsidence of the swell- 
ing being one of the most conspicuous of the immediate results of the 
treatment. (Plate VII.) 

Involution of the lupoma, or of tissue infiltrated with lupoid cells, 
occurs by resorption of that material, by fibroid metamorphosis, and 
by ulceration. These several changes separately or together furnish 
other clinical pictures of the disease. Thus the lupus lesion or patch 
may furnish scales, whitish, dirty, yellowish- brown, or even glisten- 
ing, the epidermis above and about becoming wrinkled. This pro- 
cess may be central or peripheral as respects patch or lesion, leaving 
eventually a cicatriform depression in the skin (Lupus Exfolia- 
tivus, Lupus Psoriasiforme, " Lupus Psoriasis"). When a 
fibrous metamorphosis occurs, a sclerotic mass occupies the site of the 
former lupoid tissue, which in some cases progresses to extension of the 
lupoid patch in consequence of the further production of the toxine 
of the bacilli in the site affected ; and in others furnishes a final result 
in the production of the cicatriform tissue resembling that left after 
involution without ulceration of the gumma of syphilis. (Lupus 

SCLEROSUS, SCLEREUX, FlBROSUS.) 

The degenerating forms of lupus, with ulceration, may begin by 
breaking down from without, inward, or by a more or less rapid 
transformation of patch or lesions into a cheesy semi-purulent mass of 
detritus. When pus is freely formed, whether superficially or deeply, 
crusting ensues, the debris of epidermis being entangled with the 
desiccated secretions. These crusts are variously colored and differ 
in thickness with the severity of the degenerating process beneath. 
The oval or roundish ulcers which furnish them are usually well 
defined as to margin, shallow, thin-edged, flattish, and their floors 
are dirty-reddish or purplish, indolently granulating, furrowed, 
hsemorrhagic, or when cicatrization is in progress, healthy. The 
destruction produced by involution of a lupous patch may be both 
by resorption and ulceration in the same subject and at the 
same time. The two processes may also coincide with an out- 



LUPUS VULGARIS. 561 

break of fresh lupous tubercles, which latter may develop at one 
point or another of the patch undergoing involution, probably from 
emigration of bacilli at the point of advance. In other cases lupus 
may spread by the formation of fresh nodules and plaques separated 
by islets of sound skin from those previously degenerated. When 
the ulceration advances it may be superficial, deep, or have other 
peculiarities and be subject to other accidents of the ordinary process 
of ulceration, whence the names (Lupus Serpiginosus, Profundus, 
Superficialis, Gangr^xosus, Exulcerans, Rodens, etc.). 

Lupus Crustosus and Rupioides are terms descriptive merely 
of the incrustations which form in some cases. Exuberant granula- 
tion elevating the floor of the ulcer may produce the condition 
termed Lupus Fungosus, Lupus Fungoides, Lupus Vegetans. 
Lupus Keloides indicates a cicatricial overgrowth of the scar- 
tissue left alter any one of the several conditions described above. 

One of the most conspicuous features of lupus vulgaris is its essen- 
tially chronic course. It requires far more time for its complete 
evolution than either syphilis or carcinoma ; and in this point is best 
compared with lepra. For a quarter of a century a lupous patch 
may be limited to a space no larger than the palm of the hand ; and 
exhibit some evidence of activity during the greater part of that 
period of time. 

Lupus of the Face. — Here the first manifestations are the so- 
called primary efflorescences, exhibited on one or both cheeks, nose, 
or cheek and nose, as a dull-colored maculation, or minute nodule, 
often long unnoticed, or a finger-nail sized, purplish thickening of 
the skin. Extension may then occur by multiplication of lesions, or 
by spreading of the single patch, the central parts wasting or cica- 
trizing. The contracture of the irregular scars thus resulting may 
produce an ectropion of the lid or lip, and with this is often seen 
the " bouffissure " of the features, already described. Crusting and 
ulceration may be conspicuous or well nigh absent features. Gradu- 
ally the subcutaneous tissue becomes involved. 

The nose, may, after absorption of the lupous tissue, become 
shrunken and retracted to a miniature of its former dimensions, its 
tip being noticeably reduced to a sharp point, producing thus a 
characteristic deformity suggesting the beak of a parrot. In other 
cases the point becomes bulbous, flattened, livid, and knobbed, with 
a thickened septum and distorted alse, an isolated patch or two of 
lupous infiltration showing in the neighborhood of the cheek on one 
or both sides. The last described condition may lead by degenera- 
tive processes to the first, but is more commonly noticed as a less 
severe and more localized involvement of the face, which may termi- 
nate, in favorable cases, without the severe mutilation first described. 

The subcutaneous tissue, mucous membrane, cartilages, and bones 
may be destroyed ; and in place of the nasal organ itself there may 
be left eventually two ovoid cavities in the face, separated merely by 
the posterior flange of the septum. 

36 



562 DISEASES OF THE SKIN. 

Often large portions of the skin of the head (cheeks, lips, nose, 
lids, chin, ears, brow, and neck) become altered by the lupous growth. 
The resulting thickening produces a marked and characteristic de- 
formity reducing the openings of the mouth and lids to narrow slits, 
interfering with vision, speech, and mastication, and producing a 
marasmus from these causes alone, before there is ulceration at a 
single point. 

The ravages of the disease are at times frightful in severity ; not 
merely in consequence of the destructive ulceration to which it tends, 
but from the deformity left by awkward attempts at repair. The 
entire head maybe thus converted into a hideous travesty of human- 
ity, while yet its possessor is left with all his vital organs and func- 
tions apparently unimpaired. 

The upper lip, when involved, becomes first swollen, fissured, 
hemorrhagic, and crusted, and a granulating surface indicates exten- 
sion of the disease to the adjacent mucous surface. Later, if the 
ulcer heal, the mouth, by contracture, is reduced to a repulsive 
looking slit or chasm in the face, permanently retracted, and either 
open or closed. The gums, lining membrane of the lips, velum, and 
hard palate may be also granulating, eroded, or whitish, when the 
exfoliated epithelium is in situ. Ulceration and cicatrization here 
also produce deformities interfering with the function of the parts, 
aphonia, for example, resulting from the operation of these causes in 
the larynx. 

Lupus Vulgaris of the Ears may be symmetrical in develop- 
ment, or affect but one auricle. As in eczema, a favorite point of 
election is the lobule, which, with or without tumefaction of the 
whole organ, becomes a pyriform, purplish, dependent tumor, agglu- 
tinated speedily to the cheek. Later, when ulceration occurs, the 
auricle may disappear, or be reduced to a shrunken shell of its for- 
mer state, the external auditory meatus being, by the same process, 
occluded. 

Lupus of the Trunk is, as a rule, more extensive and less 
destructive than lupus of other parts. Giant areas over the loins, 
hips, and belly may be involved in superficial serpiginous ulceration, 
the centre healing as the peripheral ring spreads. In these cases, it 
is even more difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes ; and 
then, as a rule, has extended thither from affected areas of the adja- 
cent integument. 

Lupus of the Extremities is remarkable for its interference 
with the mobility of the smaller bones of the hands and feet, as a 
result of rigid cicatrices ; and also for the production of caries and 
osseous necrosis. Mutilating effects are thus produced by loss of 
phalanges, and also by shortening of the hand or foot after the 



PLATE VII. 




LUPUS HYPEKTROPHICUS OF THE FACE. 

From a photograph of one of the author's patients. 



LUPUS VULGARIS. 563 

destruction of centrally situated bone. Elephantiasic enlargement of 
such organs as the hands and feet thus correspond to the livid tume- 
faction seen occasionally in the face. Thickenings, ridges, knobs, 



Fig. 67. 




Lupus vulgaris -of the leg. 
(From a photograph of one of the author's clinical patients.) 

nodules, warty excrescences, ulcers, crusts, and callosities are often 
commingled, and in patients of mature years strongly resemble some 
forms of vegetating and ulcerating epithelioma. 

Lupus of the Mucous Membranes may or may not mean ex- 
tension of the disease from an affected adjacent integument. The 
lupous nodule, in consequence of warmth and moisture, is here trans- 
formed into a moist papillary outgrowth, or externally granulating 
patch which may ulcerate and cicatrize. The borders of such an 
affected area are well defined, and its surface is reddish and florid, 
quite pallid, white and glistening, or of a dirty grayish-white color, 
where the investing epithelium is loosened but not yet detached. 

The soft is rather more often involved than the hard palate, but 
these parts with the tongue, larynx (epiglottis, inter-arytenoid fold), 
and gums may be extensively invaded. Often for from two to five 
years the disorder may make no apparent advance, being limited to 
patches of red, swollen, coarsely granulating, whitish or glistening 
mucous membrane, with ulcerative and cicatricial processes slowly 
resulting. The lymphatic glands beneath the jaw and in the sub- 
clavian region may be simultaneously enlarged. In connection with 
the characteristic lupoid nodules, grayish growths of the character of 
small tumors may be recognized in the larynx, with the result of 
partial occlusion of the rima glottidis. Patients may suffer from 
apicial pulmonary tuberculosis, presumed to be the result of exten- 
sion of the disease from laryngeal lupus. 

Under the title " Lupus Demisclereux de la Langue," Leloir 
(International Atlas of Rare Shin Diseases, 1889), pictures and de- 
scribes the features in the case of a girl fifteen years of age, with 



564 DISEASES OF THE SKIN. 

lymphatic adenopathy, typical lupoid nodules about the nose, and char- 
acteristic " parrot's beak deformity " of the latter. The middle of the 
dorsal surface of the tongue displayed smooth, pea-sized and larger 
sclerotic nodules, grayish-yellow, firm and softish, separated by fur- 
rows, and non-ulcerative. The palate, uvula, and larynx were in- 
volved. Tubercle bacilli were recognized and cultivated in series ; 
and inoculation of the cultures produced tuberculosis in guinea-pigs 
and a rabbit. 

Esthiomene (so-called Lupus of the External Genital Organs 
of Women). In the year 1849 Huguier published a report of cases 
under the title of esthiomSne, which have been the basis of a con- 
ception widely prevalent since that date, that lupus, of the vulva 
especially, presents certain peculiarities not displayed by that dis- 
ease elsewhere. The subject has lately been re-studied with special 
care by several observers, including the author, and last, Dr. R. W. 
Taylor, of New York, who is in practical accord with me on this 
subject. As a result, it may be stated that lupus of the genital 
organs in women does not in any special way differ from its manifes- 
tations in other regions of the body. The " esthiomene," of Huguier 
and his followers, is a complexus of differing disorders, including 
many cases of syphilitic sclerosis, secondary lesions, and gummata ; 
and hypertrophies of the genital organs due to chronic " chancroid," 
traumatisms, and inflammations of a simple character aggravated by 
filth. It is not known to be a tuberculosis of the vulva, though it is 
possible that some tuberculoses may have been included in the 
category. 

2. Tuberculosis Cutis Verrucosa. 

There are several forms of tuberculosis of the skin in which lesions, 
differing both in appearance and career from those described in con- 
nection with lupus vulgaris, have been demonstrated to be the result 
of the encroachment of bacilli of tuberculosis upon the integument. 
These lesions exhibit for the most part a verrucous, or warty appear- 
ance, and are well illustrated in the most distinctive clinical member 
of the group, the anatomical tubercle. In 1884 bacilli were fii>t 
discovered in its mass, and in the year 1886 Riehl aud Paltauf 
pointed out the connection of this lesion with cutaneous tuberculosis. 

(A.) Verruca Necrogenica. 
(Post-mortem Tubercle, Dissection Tubercle, Anatomical Tubercle.) 

Verruca Necrogenica is a vesiculo-pustular or wart-like symptom 
of cutaneous tuberculosis, situated usually on the hands, and resulting 
from contact with the bodies of the dead. 

This lesion was first named verruca necrogenica by Wilks. 1 It 

1 Guy's Hospital Rep., third series, vol. viii. p. 263. 




TUBERCULOSIS CUTIS VERRUCOSA. 565 

commonly occurs on the fingers of those engaged in the habitual hand- 
ling, or dissection of cadavers, and results both from such habitual con- 
tacts, from dissection wounds, and from all accidental inoculations with 
tuberculous virus. Cases are reported where 
the lesion has had a non-cadaveric origin. It 
begins at the site of an abrasion or wound as 
a vesico-pustule, with deep-seated base and 
reddish or reddish-purple areola. This is 
productive of a burning, smarting, or pruritic 
sensation. The lesion accomplishes a period 
of bursting and crusting, which may be fol- 
lowed by a complete involution. Several _ 
isolated or grouped papules, nodules, or &j| 
tubercules may be formed, one or a patch of 
several subsequently undergoing atrophic ; / 
changes over an area of several inches diam- ■ " 
eter. Dermatitis and suppuration, very rarely j 
ulceration, may complicate the process. The jf '&& f < ^fi/f 
typical so-called "anatomical tubercle" is / ; " : 1p" : 

indurated and horny ; and a pigmented verru- J *' 

cous papule or tubercle very slowly forms, 

i«ii n i j Verruca Xecrogenica. Model. 

which may become fissured at one or more Guy , s Mus 19350 

points. The characteristic lesion is the thick- 
ened, indolent, more or less pigmented and fissured, split-pea to bean- 
sized wart, usually single, found on the finger of the anatomist. 

In other cases, grave symptoms result, either in the involvement 
of the deeper tissues (subcutaneous, thecal, tendinous, periosteal), or 
in the production of erysipelas, pyaemia, septicaemia, or gangrene. 
Surgeons divide these cases into mild and acute varieties, accord- 
ing to the symptoms exhibited. The records of the medical pro- 
fession in almost every one of the large cities of this country con- 
tain the names of one or more of its eminent representatives whose 
lives have been sacrificed in this manner. 

Out of more than fifty-eight thousand cases of cutaneous diseases 
collected by the Statistical Committee of the American Dermatological 
Association, but one instance was reported of verruca necrogenica. 
This does not, however, exactly represent the frequency or, better, 
the infrequency of the lesion, since the majority of all such accidents 
occur in the persons of anatomists and surgeons, who destroy their 
lesions themselves without consulting others on the subject. 

(B.) Other Verrucous Lesions. 

Other verrucous lesions of tuberculous origin differ from that of 
the tubercle last described. Some, as in Morrow's remarkable case, 
exhibit on the face and elsewhere, florid tumors of papillomatous 
type ; others represent intermediate forms between the latter and the 
inflammatory papules of acneiform type. 

It is chiefly important to note in this connection that accidental 



566 DISEASES OF THE SKIN. 

inoculations with tuberculous material, produce in different cases 
different clinical results, the essential part of the result being, the 
transference of tubercle bacilli. These infections are far more common 
than is generally understood. They occur in both the young and the 
old. Fox, of London, has reported such instances at the ages of 
seventy-two and eighty-two, respectively ; and Mr. Marmaduke 
Shield has reported cases of general tuberculosis of the aged, result- 
ing from these accidents. 

(C.) An Acne Group of Tuberculoses. 

An acne group of tuberculoses unquestionably results from the 
common habit of picking and scratching the scalp, face, and beard. 
The finger-nails in these cases, especially when there is tuberculosis 
of the pulmonary organs of some member of the same family, are 
probably the carriers of tubercle bacilli. These micro-organisms 
have been recognized in a number of acne lesions, and were at first 
supposed to have no significance in this situation. The " lupoid 
sycosis " of certain writers refers to a class of cases which may be 
regarded as distinct from the simpler varieties of that disorder, where, 
after several years, persistent lesions leave atrophic and scar-like or 
simply wasted lines, points, or areas in the region of the male beard. 
Some of the disorders of the scalp termed " epilating," " cicatricial/' 
" unnamed," " follicular and peri-follicular," and " neurotic " alope- 
cias, may be one day assigned to this class of tuberculoses, since 
already bacilli have been recognized in some of them. 

Ulerythema Acneiforme. — Under this title, Unna {Intern. 
Atlas of Rare Skin Diseases, i., 1889), describes and figures a dis- 
ease on the face of a young girl, beginning with the production of 
papules in the centre of the cheek, where finally developed comedone- 
like masses ; the lesions, without suppuration, eventually leaving 
reticulated and pitted scars perceptibly sunken and traversed by dull- 
white ledges between which comedones were visible. The lesions 
were also visible about the scalp, forehead, and ear. Anatomically, 
it appeared that inflammatory symptoms resulted in a peri-follicular 
cell infiltration, with dilatation of lymph spaces and consequent 
changes in the epithelium, as well as the muscular, elastic, and other 
tissues. Unna does not seem to have suspected this to be a form of 
tuberculosis, as the latter is not named in giving a differential diag- 
nosis ; and it does not appear that search was made for bacilli, though 
he asserts that it is " probably parasitic." 

The disorder thus named represents a class of cutaneous tuber- 
culoses, many of whose manifestations resemble those of acne. A 
series of these, studied with special care, reveals the nature of the 
process where tubercle bacilli may be recognized. In an extreme 
case of this kind under the observation of the writer for several 
years, the face had been extensively disfigured with similar scars 
interspersed with comedone-like masses. There was a history of 
tuberculosis in two members of the same family. 



SCROFULODERMA. 567 

In all these cases there is the same cycle of symptoms, inflamma- 
tory redness with local distress, absence of suppuration throughout, 
infiltration, no distiuct ulceration, and eventually cicatricial atrophy, 
the scars very slightly, if at all, resembling those left after other pro- 
cesses. 

3. Tuberculosis Cutis Orificialis. 

The clinical forms included under this title were those once supposed 
to be the sole manifestations of cutaneous tuberculosis. The title 
"tuberculosis of the skin" was, in fact, applied exclusively by many 
writers to the lesions observed by Kaposi, Jarisch, Chiari, 1 and others. 
These were indolent, oval or circular, shallow, discrete, reddish-yellow 
granulating ulcers, often covered with thin crusts, occurring about 
the mucous orifices of patients affected with pulmonary tuberculosis 
(lips, anus, and vulva) and with development of miliary tubercles in 
the adjacent mucous tract. Tuberculous lesions of ulcerative type on 
the also of the nose, over the lips, and about the ear, have been rec- 
ognized in association with laryngeal, palatal, oral, pulmonary, and 
intestinal tuberculosis. 

In the case of a patient lately shown me by my colleague, Prof. 
Senn, there was a tuberculous ulcer near the anus of a patient in 
advanced pulmonary tuberculosis ; and also a well-defined patch of 
infiltration in near proximity, highly suggestive of some of the forms 
of lupus. 

An acute tuberculosis of the skin in children has been described 
under different titles (dermatitis tuberculosa acuta, tuberculose pseudo- 
ulcereuse) by Heller and Gaucher. In these cases macules, vesicles, 
bulla?, papules, and pustules, terminating in deep, crusted, roundish 
ulcers and accompanied by caseation of neighboring glands were 
found to contain bacilli ; and inoculations of cultures resulted in 
sufficiently distinct tuberculous infection. These cases scarcely 
justify their separate classification. They are properly placed with 
the clinical forms of disease termed, for provisional purposes, scrofu- 
losis of the skin. 

4. Scrofuloderma. 

Lat., scrofa, a sow. 

Scrofuloderma is a tuberculous affection of the skin and subcutaneous tissues, 
usually originating in the lymph-glands or the periglandular tissue, which 
after a process of infiltration and softening, results in degeneration by ulcera- 
tion. 

Symptoms. — The term Scrofula, or Struma, has been long and 
loosely applied in general medicine, for the purpose of designating a 
number of diseases whose real significance was unknown, and whose 
points of resemblance to each other were greatly outnumbered by 
their specific differences. The researches of the last twenty years 

1 Viertelj. f. Derm. u. Syph., 1879. 



568 DISEASES OF THE SKIN. 

have been steadily and continuously restricting this list in almost 
every department of medicine. Many of the disorders once supposed 
to be scrofulous are now known to be syphilitic. Rickets, for 
example, is properly recognized to-day as a manifestation of hereditary 
lues. In orthopedic surgery, a number of joint affections once 
believed to be incontestably of strumous origin, are known to be 
producible by traumatism exclusively. And in dermatology, no less, 
a broad advance has been made since the day when eczema, psoriasis, 
and acne were described as evidences of scrofula. 

The term, scrofuloderm, is here strictly limited to those cutaneous 
changes which occur in distinctly scrofulous subjects, and which 
are the result of tuberculous infection. Billroth's description of the 
scrofulous diathesis may here be recalled. By this term he recognized 
that condition in which there occurs at any point in the body where 
irritation has been induced, an indolent inflammation which persists 
after such irritation has ceased, which frequently terminates in sup- 
puration and caseation, and which subsequently rarely pursues an 
hyperplastic career. If with this be conjoined inflammation and 
caseous infiltration of the lymphatic ganglia or of the subcutaneous 
connective tissue ; amyloid degeneration of one or several of the 
viscera ; tumefaction of the belly ; chronic keratitis, ophthalmia, 
otorrhcea, or coryza ; a chronic arthritis (white swelling) ; a pasty, 
dirty-colored and thick, or delicate and transparent skin exhibiting 
cicatrices of old abscesses or ulcers, the general picture of the scrofu- 
lous patient may be considered complete. 

The recognition by Robert Koch of the etiological importance of 
the bacillus tuberculosis in tuberculous disease, and the demonstra- 
tion of the presence of these micro-organisms in a number of lesions 
heretofore regarded as " scrofulous," has placed this problem at last 
upon the basis of satisfactory proof. The word " scrofuloderm " 
should be hereafter strictly limited in its application to those lesions 
of the skin and subcutaneous tissue where tubercle bacilli have been 
or can be demonstrated. 

The scrofulodermata are all characterized by the occurrence of 
pathological processes in the skin, lymph-glands, or peri-glandular 
tissues, which betray the evidence of the scrofulous process. They 
usually begin as firm well-defined subcutaneous nodules, similar in 
type to the syphilitic gumma, which gradually enlarge, become 
attached to the skin, subsequently degenerate, exhibit characteristic 
ulcers, and usually terminate by no less characteristic cicatrices 
(" Gommes Scrofuleuses," " Gommes Scrofulo-tubereuleuses," " Scro- 
fuloma.") 

The typical scrofuloderm is encountered about the face and neck, 
where the lymphatic glands have long been tumid, and either dense 
or doughy to the touch. This condition is usually reached very 
slowly ; often months and years are required for its production. 
The glands may be as small as almonds or as large as the closed fist. 
Gradually a scrofulous dermatitis ensues in the skin which is super- 
imposed. It becomes purplish and thinned and finally yields, giving 



SCROFULODERMA. 569 

exit to a sero-purulent fluid mingled with caseous matter and blood. 
The pus-corpuscles of this fluid, examined under the microscope, are 
seen to be poor in protoplasm. Fistulous tracts and sinuses result, 
which undermine and perforate the skin, resulting in the formation 
of a chronic discharge and characteristic ulcers. 

The latter are far more remarkable for their borders and bases than 
for their floors. They are usually linear, occasionally elongated and 
oval, almost never circular. As a result, their uneven floors, covered 
with pallid granulations and a watery pus, are often hidden beneath 
their inverted, tumid, and uncolored edges ; or the latter may be 
thinned, stretched over a fistulous pocket, and reddish or purplish in 
color. Their bases are usually deeply attached to the subcutaneous 
tissues, and are firm or soft, never densely indurated. The resulting 
crusts are thin, tenacious, reddish or brownish, and, like the ulcer, 
often linear, rarely bulky, never rupioid. The resulting cicatrices 
are corded, depressed in irregular lines or bands, and often alternate 
with equally irregular nodules (scrofulous gummata), where the de- 
generative process has been either arrested or is still in activity. 

Rarely, enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intra- muscular tis- 
sues in the neck or even the extremities, in the course of which car- 
tilage, bone, and periosteum are melted away. Usually but a few of 
these points of degeneration, from two to six, are exhibited in one 
patient. 

Tuberculous Dactylitis, observed generally in children, is 
characterized by bulbous extremities of the fingers and toes of chil- 
dren, the skin covering the same being at times the seat of infiltra- 
tion and thickening. Dr. White (1. c.) believes this process to be 
more common than that occurring in dactylitis syphilitica. 

Suppurative Tubercular Lymph angiectasis (Hallopeau 
and Goupil) is a condition in which the scrofulo-tuberculous gumma, 
in small-nut to egg-sized tumors, forms along the lymph-vessels, of 
the lower extremity particularly, which when they break down, fur- 
nish the typical picture of the scrofulous ulcer, with its cheesy and 
watery pus, its thin edge, and its indolent career. In these rare cases 
bacilli have been recognized in the secretion. 



The Dermatoses of the Scrofulous. 

In this connection it is desirable to consider a few cutaneous dis- 
orders which, while recognized as of occurrence among the scrofu- 
lous, exhibit lesions which, at the present time, have not been 
determined to be sites of bacilli. Of this small group it may be 
remarked that they are but little represented in the records of the 
general practitioner, since they have been observed either for the most 
part on the Continent of Europe or by but a few experts in America. 



570 DISEASES OF THE SKIN, 



Lichen Scrofulosorum. 



This eruption, first described by Hebra, 1 is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, and 
belly, of millet-seed to pin-head sized, firm, flat, light to livid red, 
and grouped papules. These are occasionally surmounted at the 
apex by a minute scale, rarely by an equally small pustule. The 
lesions are at the onset isolated ; later they tend to arrange them- 
selves in coin-sized patches ; when evolution is accomplished they are 
closely set together, the surface of the skin being then of a dirty 
reddish-brown color, and covered by thin scales which are readily de- 
tached. Often a crescentic outline can be determined in a group of 
aggregated lesions. 

The course of the eruption is slow ; often the cutaneous symptoms 
persist for months without apparent change, awakening little or no 
pruritus, and followed by involution, accompanied by slight desqua- 
mation and no cicatrices. 

In 99 per cent, of all cases observed in Austria there was con- 
comitance of the general symptoms of struma named above (sub- 
maxillary, cervical, and axillary adenopathy, periostitis, ulcerative 
dermatitis, etc.), with frequent complications, such as eczema of the 
scrotum and acne cachecticorum. The disease was encountered in 
young strumous patients between the periods of infancy and puberty, 
never after the twentieth year. 

According to Kaposi, the disease consists in an exudative infiltra- 
tion of the pilo-sebaceous follicles and the peri-follicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infiltrated 
peri-follicular annex ; and its apicial scale or pustule, a mass of 
epithelial debris, or the inflammatory exudate. 

The disease is readily differentiated from papular eczema by the 
absence of itching. From the miliary papular syphiloderm it 
differs in that the lesions of the latter, even though grouped, are 
always individually distinct. The general symptoms, however, are 
strikingly different in the two diseases. Lichen scrofulosorum can- 
not be confounded with lichen planus or lichen ruber. Lichen pilaris, 
however, in a young and lymphatic patient, might readily be mis- 
taken for the disease in question. 

This scrofuloderm is rare in France, and has not yet been recog- 
nized in this country. 

The Small Pustular Scrofuloderm. 

This eruption has been described by Duhring only. 2 In the three 
patients whose cases are reported, there were disseminated pin-head 
and small split-pea sized, yellowish pustules, having a firm base and 
purulent contents visible on the extremities, especially over the hands 
and forearms. Their course was indolent. Corneous, yellowish, or 

1 See his remarks before the German Surgical Society, Fourteenth Congress. 

2 Trans. Am. Derm. Assoc, Fourth Annual Meeting, Chicago, 1881, p. 29. 



TUBERCULOSIS CUTIS. 571 

gray-tinted crusts succeeded, leaving a marked " punched-out " scar. 
Relapses occurred, the entire process lasting for months and years. 
The general symptoms of struma were present in each case. The 
disease is to be distinguished from the small pustular syphiloderm, 
acne cachecticorum, and follicular lupus. Microscopic examina- 
tion of the lesions exhibited unmistakably a non-follicular origin of 
the disease. 

The Large Pustular Scrofuloderm 

is described by the same author as a rare eruption, constituted of 
large, roundish, flat pustules, with a deep red or violaceous areola. 
A thin, flat, brownish, and adherent crust partially or completely 
covers each lesion, after the desiccation of its yellowish contents, and 
beneath is found a shallow ulcer of scrofulous type. One, two, or 
more lesions may exist, often over the sternum, where they leave 
superficial cicatrices. There is concomitance of the general symptoms 
of struma. 

The "Tuberculous Eczema" (of Unna) is merely an exudative 
affection, which may be recognized in proximity to the scrofulo- 
dermata, a process awakened by the irritative effects of the latter ; 
or occurring, as do other affections, in scrofulous patients. 

Lupus Erythematosus (consult the following chapter) is by some 
authors classed with the disorders grouped under the title of tuber- 
culosis cutis. The evidence that it is itself a cutaueous tuberculosis 
is not satisfactory. That, however, it may be in some cases a derma- 
tosis of the scrofulous can scarcely be questioned. Hallopeau and 
Jeanselme, for example (Annales de Derm, et de Syph., 1891, t. ii. 
8-9), report the case of a man thirty-five years of age, tuberculous 
since early life, with characteristic cicatrices of a ganglionic scrofu- 
losis visible in the skin, and no less characteristic adenopathy of the 
neck, perishing eventually of miliary tuberculosis, who had charac- 
teristic patches of erythematous lupus on the face. Histological 
examnation revealed no bacilli in the lupous tissue, and the results 
of inoculations were wholly negative. 

The evidence, as regards some of these forms, which may be, per- 
haps, classed with the " pseudo-tuberculoses," is instructive. The 
results of inoculation of tuberculous material in different lower ani- 
mals seems to establish the fact that scrofuloderma, tuberculosis cutis, 
and lupus vulgaris differ in a marked degree as respects the number 
of bacilli that can be recognized in their respective lesions. It is 
hence argued that with even fewer micro-organisms present, types of 
tuberculosis may exist still further removed from those here classified. 

Etiology. — Accidental inoculation of tuberculous virus may occur 
at all ages and in all sexes. There is, however, ampler oppor- 
tunity for such transmission among the members of any family 



572 DISEASES OF THE SKIN. 

where pulmonary tuberculosis exists ; hence the widespread belief in 
the hereditability of the disease. Attention has, however, been 
already directed in these pages to the striking fact that no child is 
ever born into the world tuberculous ; and the possibility of explain- 
ing all cases of reputed inherited tuberculosis by transmission from 
the actually infected, can never be ignored. 

Given, however, an infective micro-organism, the soil upon which 
it may most favorably flourish is of paramount interest in an etio- 
logical view. The young, the delicate, the cachectic furnish such a 
culture field. With these must be included, as favoring such acci- 
dents, the mode of life of the very poor, the filthy, and the degraded. 

Thus, lupus vulgaris is seen to be declared first in the majority of 
all cases during the first decade, between the third and sixth years of 
life ; rarely after the thirtieth year, for the reasons above given. The 
author was early in calling attention to the significant fact that at 
this period of life the child often deprived of the constant care of a 
mother by the demands made by a still younger infant, untaught in 
the simplest rules of cleanliness, picking and scratching the face after 
miscellaneous contacts of the fingers with all sorts of material, is 
exceedingly liable to inoculate the skin of the face with tuberculous 
virus, if there be victims of such disease occupying the same apart- 
ment or house. It is significantly first upon the face in these early 
years, and next over parts such as the extremities, or the genital 
region, to which the exposed hands have been carried, that the early 
symptoms of lupus vulgaris are betrayed. Further, it is significant 
that well-marked cases are more frequent among the poor, the filthy, 
and the degraded than among the comfortable and cleanly. The 
prevalence of the disease in public as contrasted with private prac- 
tice is conspicuous in all statistics. 

As throwing additional light upon this question of childhood 
infection, it is to be noted that other forms of tuberculosis occur at 
any period of life and in both sexes, when the accident of infection 
operates. Thus in verrucca necrogenica and warty growths of the 
same nature, it is the contact with bodies of the dead or with tuber- 
culous matter in any form, which determines the result. The aged 
with tuberculous lesions upon the backs of the hands, and middle- 
aged persons with other evidences of cutaneous affection, actually 
suffer from generalized tuberculosis as a result of the accident. 

What may be said of the causes of lupus vulgaris relates also to 
scrofuloderma, which while occurring in both sexes and at all ages, 
is more frequent in early life because of the susceptibility of the 
tissues at those periods. The difference between its manifestations 
and those of other clinical forms of tuberculosis depends in large 
part upon the attenuation of the virus, seeing that relatively fewer 
tubercle bacilli are to be recognized in its characteristic lesions ; and 
the results of inoculations of cultures as respects the lower animals 
is markedly different. 

The soil fittest for scrofulodermatous manifestation is that where 
well-known agents have been most efficiently at work. 



TUBERCULOSIS CUTIS. 



573 



All causes which tend to impair the nutrition and vigor of the 
body are, to an extent at least, efficient in its development, including 
privation from sunlight, fresh air, wholesome food, exercise, and 
hygienic influences in general. It is common among prisoners, exiles, 
and, in this country, among negroes and those of mixed blood. Con- 
sanguineous marriages are said to result often in strumous offspring. 
Syphilis in the third and fourth generation, is known to be patho- 
logically distinct from all of its manifestations. In many cases it is 



Fig. 69. 




d d 

Section of a lupous nodule, a, reticulum with lupous elements in groups ; b, normal corium ; 
c, d, giant cells. (After Kaposi.) 

the sequence of other depressing medical diseases and surgical acci- 
dents. In other instances, especially where it is limited to the neck, 
and accompanied merely by a cervical or submaxillary adenopathy, 
it is consistent with full vigor and nutrition of the body and all other 
evidences of sound health. 

Pathology. — The anatomy of all lesions termed tuberculous 1 ex- 
hibits evidence of tubercle bacilli in varying proportions. That all 
tuberculoses of the skin are related, depends on this essential fact. 

1 Relations of Lupus Vulgaiis to Tuberculosis. Journ. of Cutau. and Vener. Dis., Nov., 1885. 



574 DISEASES OF THE SKIN. 

Other significant facts are, that several forms of the disease may be 
recognized simultaneously or successively in the same persons, and 
that inoculation and auto-inoculation have been followed by charac- 
teristic infective results in a large number of observed cases. It 
follows from what precedes that pulmonary and other forms of vis- 
ceral tuberculosis have occurred both coincidentally and consecutively 
with the accidents of tuberculosis cutis in all its clinical varieties, 
with and after lupus vulgaris, verruca necrogenica, scrofuloderma, 
and acneiform and other lesions similarly infected. 

For a knowledge of the microscopic characters of cutaneous tuber- 
culosis we are largely indebted to the Germans, whose opportunities 
for the study of the disease are unequalled. Yirchow, Auspitz, 
Billroth, Lang, Kaposi, Klebs, Stilling, and Thin, of England, have 
amply contributed to the subject ; and the result of their investiga- 
tions may be concisely stated as follows : 

The tubercle of cutaneous tuberculosis is a nodule of granulation tissue. 

The more recent nodules when divided exhibit at different depths 
of the corium roundish masses comparable to a nidus or nest, above 
which spreads an unaltered epidermis. These foci of the disease are 
well defined in outline, and of a reddish-yellow tint. They con- 
tain small roundish cells, deeply stained by coloring agents ; larger 
cells with a clear nucleus, epithelioid in type; and " giant cells " 
homogeneous centrally and peripherally displaying multiple nuclei. 
Around them is woven a network of connective-tissue bundles, 
with larger and smaller interspaces containing vascular elements, and 
also cells and nuclei, probably masses of protoplasm, unstable of 
structure, originating in the reversion of the connective-tissue ele- 
ments to the embryonal state. Retrogression is marked by a dimin- 
ished vascularity ; while the elements disappear by resorption, or by 
the destructive process of ulceration, coagulation necrosis followed 
by the cicatrix. Both Kaposi and Lang agree that the vascular and 
fibrous elements of the mass are capable of developing new connec- 
tive-tissue which later undergoes retraction. This is curiously in 
accord with the clinical result of treatment by multiple linear scarifica- 
tion, in which the lupous growth, after replacing the normal elements 
of the derma, becomes itself the source of the new material of repair. 

When the disease is extending, the new growth, spreading along 
the vascular elements of the derma, involves finally the rete and the 
panniculus adiposus. The nest-like agglomerations disappear ; there 
is in their stead an irregularly diffuse infiltration, producing subse- 
quently hypertrophic, atrophic, desquamative, suppurative, or ulcera- 
tive sequelae. Finally, the glands of the skin may become involved, 
the hairs falling from their follicles, the sebaceous glands either 
becoming obliterated, or having their acini stuffed with epidermal 
masses which distend them in milium-like bodies grouped about a 
cicatricial pedicle. When, as observed by a few authors, there is coin- 
cidence of tuberculosis and epithelioma, the latter is developed from 
epithelial cones, described by Kaposi as penetrating downward and in 
other directions from the coil-glands and the root-sheaths of the hairs. 



TUBERCULOSIS CUTIS, 



575 



The discovery of bacilli in lupous tissue, first made by Koch, has 
been since verified by Doutrelepont, Weichselbaum, Meisels, Schuller, 
Lustig, and others. The striking resemblance first shown by Vir- 
chow between a caseous miliary tubercle and a lupous nodule had, 
even before his discovery, pointed to an identity of origin. 

The result of inoculation of culture fluids has given positive 
results. Lenz, Huter, Schuller, and many others, have produced 
tuberculosis in rabbits by introducing within the eye granulations 
taken from lupous, scrofulous, and other infected patients. 

Fig. 70. 




Section of lupus of face, x 750 and reduced. (Delafield and Prudden.) 



The bacilli of lupus are rod-shaped, and in length from one-fourth 
to one-half the diameter of a red blood-corpuscle. They are usually 
found within the cells, and commonly but one is visible in a single 
cell. They are, however, also found free in the lupous tissue. Some 
contain roundish or oval spaces. They are more abundant in recently 
formed lupous nodules exhibiting some pathological activity. 

The action of these effective micro-organisms is first to impress 
the normal cells at the site of the tubercle. After assumption of the 
epithelioid shape the infiltration results in an increase of the number 
of leucocytes in the part, which, varying in number according to the 



576 DISEASES OF THE SKIN. 

intensity of the virulent effect of the invasion of the colony of micro- 
organisms, eventually degenerate, with the result of producing the 
so-called cheesy metamorphosis. When suppuration occurs in the 
site of this invasion it is an accident of the process, and its results 
and significance are those of the septic condition. Whether, accord- 
ing to the view of Metschnikoffj the white blood-corpuscles are pha- 
gocytes, digesting the bacteria and by enlargement producing the 
Langhans " giant cell," is not yet fully proved. It is probable that 
the failure to proceed to a pure karyokinesis on the part of the pro- 
toplasm, rather than a confluence of several contiguous cells, is re- 
sponsible for this " tubercle in miniature," the giant cell. 

The study of other forms of tuberculosis than lupus is that of 
invasion of the skin by tubercle bacilli in forms differing largely 
because of the number of bacilli present in each. In the " orificial " 
forms of tuberculosis cutis, Howe (loc. cit.) states that in the number 
of bacilli present there is an analogy with miliary tubercle of other 
organs. Enormous masses of bacilli were present in the cases exam- 
ined by him. Specific tubercle bacilli are also invariably present in 
all forms of scrofuloderma ; often less abundantly shown, and more 
difficult of detection than in lupus, and less numerous than in the 
cutaneous tuberculoses usually ulcerative in type found near the 
orifices of the body. In the structure too of verrucous tuberculoses 
bacilli are found, yet very sparsely, their recognition often demand- 
ing long and laborious search. Anatomically the papilla? are found 
elongated and enlarged, and covered with a thickened and laminated 
stratum corneum, with foci of granulation tissue in the upper part of 
the corium. Round cells are seen at the periphery, and the giant cell 
of Langhans, with epithelioid cells toward the centre, where often 
necrosis is in progress. At other points there are foci of suppura- 
tion, where eventually crypts are formed filled with horny masses 
from the corneous stratum of the epidermis. 

Diagnosis. — Epithelioma, though rarely resembling lupus vul- 
garis, is more often designated by that than by any other false title. 
Great confusion has arisen from the looseness with which several 
surgical authors have furnished illustrations of " lupus exedens," 
which were really pictures of cancer. But the latter is more rarely 
a disease of early life, and when of such early occurrence may 
not persist to adult years ; while lupus is such exactly in the 
majority of all cases first examined. The nodules of lupus are 
absent in epithelioma, and the evolution of the disease slower, less 
painful, and, in its earlier periods certainly, of deeper situation. 
The ulcer of epithelioma is more often defined and single ; its edges 
whitish, indurated, and everted; its floor uneven and glazed; its 
secretion scanty and occasionally fetid ; its base a mass of indurated 
tissue. Lupous ulcers are often ill -defined and multiple ; their 
edges, soft and inconspicuous, neither everted nor undermined ; their 
floors granulating and flattened ; their secretion relatively profuse 
and generally odorless ; their bases soft and pliable, though occasion- 
allv indurated. 



TUBERCULOSIS CUTIS. 577 

Tubercular, serpiginous, and ulcerative lesions of syphilis often 
resemble certain forms of lupus. In any doubtful case a history of 
infection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in the female, etc., should aid in the recog- 
nition of syphilis. The suspected lesions should be carefully ex- 
amined for the purpose of distinguishing characteristic lupous nodules 
in the patch itself or in the periphery of any exfoliating area. In the 
case of an adult, a long history of lupus can often be obtained ; and 
it is worthy of note that syphilis with exceeding rarity displays for 
long periods of time a single exanthematous lesion or aggregation of 
such lesions in one part of the body exclusively. Lupous ulcers, 
often multiple and isolated, insensitive, rarely of well determined 
outline, never reniform or horse-shoe shaped, with supple, low edges, 
and reddish, smooth, hemorrhagic granulating floor, covered with 
crusts like soiled parchment of uniform thickness, do not resemble 
those of syphilis. The latter are often painful, single, circular, and 
clean-cut in contour, with firm, raised, infiltrated margins, and with 
offensive greenish and blackish crusts, resembling oyster shells. The 
cicatrices of syphilis are elegant, smooth, delicate, superficial, cir- 
cular, and, after pigmentation has disappeared, dead-white in color. 
Those of lupus are irregular, indurated, deforming, yellowish- white, 
and reddish-yellow. 

Acquired syphilis is a disease of adult life; lupus commonly begins 
in childhood. 

The disks of psoriasis are distinguished from flat exfoliating 
patches of lupus vulgaris by the relatively large number of the 
former, the nacreous lustre of the scales, the reddish hemorrhagic 
surface beneath, and the sites of election of the disks, usually on the 
extensor faces of the limbs. 

Lupus erythematosus is even more readily distinguished by its 
characteristics ; including the absence of nodules, ulcers, and crusts, 
the superficial character of the morbid process, the scaliness, and 
occasional symmetry of the patches. Cases are described of interme- 
diate forms between lupus erythematosus and lupus vulgaris, but 
these are rare. The two diseases, unfortunately somewhat similar in 
name, are distinct in character. The so-called intermediate forms 
may be instances of flat and scaling epitheliomatous infiltration 
going on to ulceration. 

In acne and rosacea with a bulbous condition of the tip of the 
nose, the redness is vivid ; and the telangiectasic complications, with 
the seborrheic flux, are conspicuous points of difference from lupus 
vulgaris. There is further no ulceration and little scarring, and the 
patients have usually suffered from the disease only after arriving at 
maturity of life. The mucous surfaces are also spared. 

The Diagnosis of verrucous growths of tuberculous nature is to 
be made chiefly by au investigation of the history of each case, which 
often includes a record of contacts with bodies or persons capable of 
commuuicating the disorder. The epitheliomatous warty growths on 
the dorsum of the hands of elderly persons are not to be confounded 

37 



578 DISEASES OF THE SKIN. 

with tuberculous lesions. In the former there is commonly a his- 
tory of longer existence of the wart, and no record of suspicious 
contacts ; while a careful search will usually determine epithelioma- 
tous metamorphoses over the cheeks or temples of the elderly man 
or woman with epitheliomatous warts on the hands. In the latter, 
too, the facial lesions are usually multiple fatty-looking scales, thicker 
in one part than another, resembling those of a severe seborrhoea, but 
which are removed with some difficulty, and then leave a bleeding 
surface beneath. 

In the orificial cases it must be remembered that tuberculosis 
of the viscera is a probable coincident disease. The microscope is 
usually needed for an exact diagnosis 

The acneiform and sycosiform tuberculoses, many of them in- 
stances of implantation of tubercle bacilli upon simple lesions, are 
distinguished by anomalous symptoms occurring where none such 
was to be expected. For example, a sycosis, apparently simple, 
leaves persistent disfiguring infiltrations, with scar-tissue and even 
ulcerative effects ; the acne which should resolve, exhibits deep 
sunken cicatriform pits, or papules which ulcerate ; the alopecia of 
the scalp which at first seems to be of simple type, results in charac- 
teristic changes of the deep tissues. 

Treatment — The internal treatment of tuberculosis cutis is practi- 
cally that indicated by the condition of the patient ; inasmuch as no 
medicament is known to be capable, after iugestion, of relieving the 
victim of his local ailments. Of the articles in this category none 
will be more often indicated than cod-liver oil, the chalybeates, the 
bitters, the preparations of iodine, and possibly phosphorus. Dr. 
Fox, of New York, praises the iodide of starch. Iodoform and the 
iodide of potassium have been recently freshly recommended by 
Neisser, who employs the former in pills, each containing half a grain 
(0.033). The hypophosphites are useful in many cases. Arsenic 
and mercury are powerless to prevent the extension of the disease. 
With these, it is needless to add, a diet of the most generous char- 
acter is to be supplied, and the rules of hygiene enforced. 

Patients of this class manifest in the highest degree the beneficial 
effects of a change of residence and climate — to the seashore or moun- 
tains from the interior valleys or plateau lauds ; often the reverse, for 
those who reside by the sea or in mountainous countries. It is the 
change which seems to produce the greatest benefit. A free supply 
of oxygen in an abundance of pure air and a life permitting out-of- 
door exercise is of the highest importance. The thermal and other 
springs of several countries furnish resorts where the benefit received 
is proportioned to the salubrity of the climate rather than to the 
special advantages of the waters furnished. 

Unfortunately, a large number of the patients affected with lupus 
and scrofuloderma are the impoverished inmates of public charities 
or applicants to dispensaries, where these aids in the management of 
their ailments cannot be utilized. 

The local treatment of lupus vulgaris should have in view the 



TUBERCULOSIS CUTIS. 579 

removal of the morbid growth as painlessly and with as little result- 
ing disfigurement as possible. These ends may be attained both by 
surgical measures, and by chemical and other applications. 

The surgical procedure most frequently employed is curetting with 
a sharp spoon. This, with all other bloody operations in lupus vul- 
garis, labors under the disadvantage of the possibility that tubercle 
bacilli may be disseminated by the traumatism. Competent authors 
are arrayed on both sides of this question. For myself, I am con- 
fident that small lupoid patches may be spread after resorting to most 
of the devices employed as remedial agents. 

The dermal curette is a sharp-edged spoon with or without a 
fenestrum in the bowl to permit escape of debris. By it, the lupous 
growth may be completely scraped away, and, if necessary, caustics 
subsequently applied. Fox and others substitute the dental burr or 
dental excavator for the sharp spoon, though the change is not 
always for the better. Morris's double parallel screw excavator is 
an improvement on the common burr. Often it is well to supple- 
ment the action of the spoon or excavator with the flat electrode 
treatment of Dr. G. T. Jackson. Gartner and Lustgarten originally 
used as an electrode a flat silver plate attached to the negative pole 
of the battery, the plate being set in a hard rubber ring. A current 
of from five to eight milliamperes is employed. 

The ablation of the entire lupous patch by the modern methods ot 
surgery, followed by skin grafting with the Thiersch method and its 
later substitutes, is an efficient mode of treating many cases. The 
objections to it are chiefly that it involves the production of a larger 
and more conspicuous scar, since, as a rule, more tissue is removed 
by the knife than by the curette and its allies. 

The local treatment of lupus vulgaris by the aid of parasiticides 
is based upon the infectious character of the disease ; and in many 
cases is brilliantly successful. Dr. White, of Boston, 1 with a view 
to its parasitic action, applies to the lupous patches rags soaked in 
solutions of the bichloride of mercury, one to two grains to the 
ounce (0.066-0.138 to 32.), and also applies ointments containing the 
same quantity of metal in the ounce of salve-basis. The favorable 
results obtained by him have been again and again verified by the 
author, who is in the habit of freely painting lupous ulcers with a 
solution of corrosive sublimate in the tincture of benzoin of the 
strength named. Salicylic acid, two to four per cent, solutions in 
castor oil ; and in ointments, half to one drachm to the ounce (2.-4. 
to 32.) ; sulphurous acid (Hutchinson) ; pyrogallol (Neisser) in ten 
per cent, to fifty per cent, strength (Fox) ; ointments, spread on linen 
rags, covered with impermeable tissue, and followed by the use of 
mercurial plaster and iodoform, have all been successfully employed 
with the same object in view. 

Decidedly inferior to these are the following methods, the first 
named, most popular in Germany ; the second, in France ; the third, 
to-day practically obsolete, and probably not to be revived. 

Boston Med. and Surgical Journ., October 29, 1885. 



580 DISEASES OF THE SKIN. 

The Paquelin knife is extensively used in Vienna. The finer 
blades especially manufactured for the purpose, are thrust, at a red 
heat, again and again through the lupous tissue until it is destroyed 
in its depth. Over the whole the lower blade is firmly passed and 
pressed, the blackish coal resulting being the best subsequent dress- 
ing after the serous exudation ceases. Erasion is also followed by 
the galvano or ther mo- cautery. 

Multiple linear scarification, a modification of the Dubini-Volk- 
mann method, was once claimed to have changed the prognosis of 
the disease. It is somewhat doubtful whether anything is to be 
gained by either a preliminary freezing of the part or the use of 
cutting instruments of many blades. The incisions may be produced 
with a delicate bistoury held in the fingers like a pen. They should 
be in parallel lines, closely set together, and crossed ; should extend 
completely through the depth of the lupous growth ; and this is 
determinable after some practice by the cessation of the creaking 
resistance which the blade fails to discover in normal tissue. Fur- 
ther, they should extend laterally beyond the borders of the lupous 
patch into the sound peripheral zone. The bleeding is trifling and 
readily arrested by firmly pressing small pieces of fine sponge, lint, 
or absorbent cotton over the part. The edges of the incision unite 
either by granulation or first intention ; and in both cases seem to 
serve as starting-points of the reparative process, the material for 
which, as already pointed out, seems to be supplied from the lupous 
nests themselves. Subsequent operations, when needed, require a 
previous freezing of the affected surface. In France and in some 
portions of the British Empire this method is still popular. 

Treatment by chemical cauterization alone is obsolete. The 
various acids and alkalies, particularly the hydrate of potash and 
lactic acid, Cosmo's paste, nitrate of silver, arsenical, mercurial, 
and zinc compounds, and the ethylate of sodium have all been thus 
employed, and in suitably selected cases have been in the past pro- 
ductive of fairly satisfactory results. 

After destructive effects are produced, or even before interference, 
medical or surgical, simple local applications may be made, such as 
oily and fatty substances for the softening of crusts ; stimulating 
dressings of tar, iodated glycerin, thymol, ichthyol, carbolized gly- 
cerin, iodized phenol, naphthol, chrysarobin, and iodoform ; as also 
the carbolated unguents appropriate for the reparative phases of the 
ulcer left after the destruction of the lupous growth. 

Unna has lately advocated the topical application of two parts of 
beech-tar creasote to one part of salicylic acid, the latter for its 
marked effect upon lupous tissue, and the former for what is sup- 
posed to be its anodyne effect in obtunding the pain produced by the 
action of the acid on the surface. That this explanation of the effect 
of the combination is not wholly correct, is shown by the well-known 
fact that creasote alone is capable of producing a curative effect upon 
lupous tissue. In a former edition of this work, issued before the 
date of Unna's experiments, creasote was set down as the dernier 



TUBERCULOSIS CUTIS. 581 

ressort of the writer. It can be used with the greatest advantage 
not only in severe cases by being brushed freely over the part, but in 
the combinations suggested by Unna. It will be found that when 
employed alone it is far from producing at first the local effect of a 
u morphine of the skin/' being productive, where no cocaine has 
been previously employed, of exquisite pain, which, however, is usu- 
ally short-lived. It should be applied only with the greatest caution 
by the practitioner's own hand ; and its effect watched, and, if need 
be, counteracted, as in the local employment of hydrated potash. 

The application of fuchsine in 1 or 2 per cent, alcoholic solutions 
painted over the part, which has been previously scarified, is advo- 
cated by Fox and others. 

The results of the injection of tuberculin (Koch's lymph) in the 
treatment of lupus and scrofuloderma have been given to the scien- 
tific world in a mass of literature whose bulk has been scarcely 
equalled by that issued in connection with any other therapeutic meas- 
ure. Whether it shall or shall not in the future be revived as an 
efficient means of treating tuberculosis of the skin, is to-day uncertain. 
In some of the German hospitals the lymph is still injected, and, it 
is claimed, with a larger success than follows the older methods. In 
France, England, and America its use is practically abandoned. It 
has not been unattended with danger ; and fatal results have in sev- 
eral instances been recorded after its injection. In other cases general 
tuberculosis has been induced ; while in yet others the degree of 
improvement following its employment has been inferior to that more 
readily reached by the curette and the topical use of mercury. 

The treatment of verruca necrogenica and other verrucous tuber- 
culoses of the skin is practically that of lupus vulgaris. The curette 
may be followed by one of the caustics advocated above, preferably 
by pyrogallol, or the combination of salicylic acid and creasote. As 
a rule, the mercurial lotions and salves are not well adapted to pene- 
tration of the warty or corneous envelope of the growth. 

The orificial lesions of tuberculosis cutis may, however, be well 
treated by these lotions, especially that in which J to 2 per cent, 
of mercuric bichloride is dissolved in the compound tincture of 
benzoin or tolu. 

The local lesions of scrofuloderma may require the use of hot 
borated lotions applied temporarily, or kept permanently in contact 
on compresses covered by impermeable tissue. The results of surgical 
ablation of enlarged lymphatic glands, broken down or threatening 
scrofulous " gummata," and the complete disinfection and aseptic 
treatment to the point of cicatrization of the resulting wounds, fur- 
nish the most brilliant proofs of the real progress of modern surgery. 

In the local management of lichen scrofulosorum, Hebra recom- 
mended the topical use of cod-liver oil smeared over the lesions, with 
woollen garments worn outside. At present the medicated pastes are 
preferable. The local treatment of the dermatoses of the scrofulous 
is, in fact, that indicated in each separate case. 

The Prognosis of tuberculosis of the skin in all its manifestations 



582 DISEASES OF THE SKIN. 

is in the highest degree variable. Many cases of lupus vulgaris, even 
after the production of the severest grade of deformity, recover, and 
without further local manifestations gain a degree of facial comeli- 
ness that is marvellous. The scrofulodermata in the same way are 
remarkably improved, in the vast majority of all cases, by skilful 
medical and surgical management. In other cases, systemic tubercu- 
losis develops after even a single tuberculous infection, and grave 
results occur either early in life or even after years of tuberculous 
involvement of the skin and other organs. Other things equal, the 
prognosis in tuberculosis of the skin, as compared with that of other 
organs, is relatively favorable, due to the sparsity of the tubercle 
bacilli in many cases of the former, and also to the poorer field for 
the development of new colonies exposed largely in the integument 
to external influences. Any form of tuberculosis of the skin, how- 
ever, may result in systemic infection and death. 

Lupus Erythematosus. 

Lat., lupus, a wolf. 

(Lupus Sebaceus ; Lupus Superficial ; " Scrofulous Ringworm ;" 

Seborrhcea Congestiva ; Lupus Erythematodes ; Lupus 

Non-exedens.) Fr., Scrofulide Erythema- 

teuse ; Erytheme Centrifuge. 

Statistical frequency in America, 0.385. 

Lupus Erythematosus is a cutaneous new growth, displayed in well-defined, 
slightly raised, discoid patches, often with a depressed or atrophied centre, 
colored in various shades of hyperemia, covered with adherent, yellowish- 
gray scales, and terminating, after a favorable involution, by the production of 
a persistent scar. 

This disease was first described by Biett under the title Erytheme 
Centrifuge. Hebra, in 1845, described it among the seborrheas, as 
Seborrhcea Congestiva. Its present title was given by Cazenave in 1 850. 

Symptoms. — The disease is first exhibited in one or several rape- 
seed to bean-sized, reddish maculae, slightly elevated from the surface, 
and covered with a peculiar glistening epidermis, or with an adherent 
scale. 

When but a single patch is formed, the primary lesion described 
above enlarges its periphery, in the course of months or years, by a 
slowly continuous development. Its reddish outer rim is then dis- 
tinctly elevated, while its centre is depressed, showing either adherent, 
yellowish-gray scales, or a glistening appearance of the unbroken 
epidermis. It may thus attain the size of a small coin or a large 
saucer, and occur in this form symmetrically or asymmetrically about 
the cheeks, nose, eyelids, forehead, ears, scalp, mouth, hands, and 
feet. The disks or patches are very well defined in outline, and of a 
color varying with the complexion of the patient, from a rosy-pinkish 
to a deep purplish hue. The shape is usually circular, oval, or in 
figures representing combinations of these outlines. The scales, too, 



LUPUS ERYTHEMATOSUS. 583 

vary in color, being at times of a clear white or whitish yellow, and 
again, often from concurrence of comedones, of a leaden or brownish 
tint. The latter are usually scanty and adherent, but are also, rarely, 
abundant. They can be occasionally seen firmly fastened to the 
orifice of the excretory duct of a sebaceous gland. When such a 
patch spreads symmetrically over the brow and cheeks its figure has 
been likened by Hebra to the open wings of a butterfly. 

When the maculae originate as multiple lesions the evolution of 
the disease may be accomplished by increase in the number of the 
former, rather than, as just described, by the peripheral extension of 
a single patch. The disease is then apt to be manifested, not only 
in the regions named above, but over the trunk and extremities, 
where it is likely to assume atypical forms, and be complicated by 
accesses of a febrile or neuralgic character, and by various cutaneous 
accidents, such as erysipelas, dermatitis, etc. 

The several forms of lupus erythematosus are differently classified 
by observers. They are in most cases distinguished chiefly by these 
clinical features : 

(a) The telangiectasic forms. Here points, spots, plaques, or large 
disks of the surface, chiefly of the face, usually well defined, present 
a rosy-reddish, deep-purplish, or yellowish color, which disappears 
under pressure. When examined with care the color is seen to be due 
to dilatation of the cutaneous vessels. The surface may be then either 
slightly cedematous or infiltrated, and, to a slight degree, elevated. 
The epithelial surface exposed to the eye may be smooth, shining, 
and dry ; or covered with either dry or fatty scales, sometimes ad- 
hering firmly to the excretory orifices of the ducts of the sebaceous 
glands. The centre of the plaque or coin-sized or larger disk is com- 
monly flattened or depressed, and in the course of the disorder either 
returns to the normal condition of the skin or leaves a characteristic 
dotted or stippled cicatrix. 

Several sub-varieties of this form may be recognized. In the 
simplest, the lesions described above appear with or without marked 
symmetry over the scalp, face, ears, and other organs, with either 
dry or fatty scales on the surface of the disks, slowly progressing to 
an extreme development, and, when occurring upon the scalp, remov- 
ing the hairs somewhat as in alopecia areata. 

An exanthematic variety occurs in both circumscribed and general- 
ized lesions. In the former the symmetry is well marked, and the 
eruptive symptoms occur with subacute, intermittent, or remittent 
development. Some of the patches resolve without leaving trace of 
their existence ; others leave the persistent and indelible cicatrices seen 
in more typical cases. The reddened plaques are, by several authors, 
likened to the lesions of exudative erythema, being hot to the touch, 
tender, raised, and manifestly centrifugal in their mode of extension. 
The erythematous aspect of the eruptive symptoms is highly char- 
acteristic. Here, as in other forms of the disease, the appearance of 
the bat's wing in the disks, on either side of the nose, with a strip 
along the bridge, may be well marked. 



584 DISEASES OF THE SKIN. 

The generalized lesions also may disappear without leaving traces 
of their existence, or may also leave characteristic thin, white scars. 
As a rule, the lesions first appear on the face, but later they develop 
on any part of the body, and usually large surfaces are involved. 
At times the subjective sensations are severe (itching, burning, heat, 
etc.), and the patches may even be the seat of vesicles, pustules, 
or bullae which eventually accomplish crusting, the parts beneath the 
crusts showing characteristic patulous orifices of the ducts of the 
sebaceous glands (Lupus Disseminatus, Lupus Iris). As in erythema 
multiforme, there may be in these cases coincident febrile symptoms, 
erysipelatous changes, and involvement of the joints and bones. In 
rare cases there are malignant symptoms, the patient soon dying of 
marasmus, tuberculosis, anaemia, or grave renal disease. Here the 
skin lesions are manifestly merely surface symptoms of a general 
process. Here, also, are to be classed the forms upon which French 
and other authors base their convictions that lupus erythematosus is 
one of the manifestations of what was once known as " scrofula.' 7 
That the disease may be at times one of the dermatoses of the 
scrofulous has been already shown in the chapter on lupus vulgaris. 

One of the interesting forms of this class of lesions is exhibited on 
the fingers and toes particularly, but also on the hands and feet, 1 
beginning as a more or less persistent erythema of the type of pernio 
(chilblain), often scaling and resolving, as noted in the other cases of 
this type, either without or with characteristic scarring. In some 
cases the verrucous aspect of the patch on the hands is well marked, 
the thickened epidermis rising to a marked degree above the general 
level, with a reddish or purplish border about the periphery. Fissures 
may complicate this condition ; often when the hands are used in 
manual labor the soreness is a marked feature of the disease. 

A last sub- variety is recognized on the face, hands, and other regions, 
where the symptoms present the characters of local asphyxia {digiti 
mortui). Here the influence of the trophic nerves, as in other con- 
ditions with similar symptoms, is distinct. The disease begins with 
the appearance of livid spots in the regions named, which persist for 
months or even years, and eventually degenerate at the centre, leaving 
a slough, beneath which lies an ulcer. In these cases, also, tubercu- 
lous complications occur in the joints. 

(b) The follicular form. In this form the hyperaemic or telan- 
giectasia symptoms are less apparent. The eruptive lesions are 
usually in discrete or confluent points, disks, or plaques, with 
definite borders, and covered with dry, whitish, or whitish and gray- 
ish scales or a scaly pellicle, firmly adherent, and obviously attached 
at the orifices of the sebaceous glands. This is the common type of 
lupus erythematosus, and is seen on the scalp, the tip, bridge, and 
alee of the nose, the circumorbital regions, the lips, cheeks, and all 
portions of the surface. In some cases the erythematous redness, in 
others the crusted surface of the disk, is the more pronounced feature. 

1 Cf. contributions to this subject by the author, Journ. of Cutan. and Ven. Diseases, 1884, 
vol. ii.; and by Ohmann-Dumesnil, Ninth Intern. Med. Congress, 1887. 



LUPUS ERYTHEMATOSUS, 



585 



The outlying area of each disk may be crusted, reddened, or pig- 
mented. As a rule, the ledness fades centrally and increases at the 
periphery, where the surface is slightly elevated as distinguished from 
the depressed or more rarely level centre. Often the surface of 
the patch is very irregular, scale-covered, the spots of adherent 
scales being distinctly circumscribed within the general enclosing area 
of the disk. The characteristic thin white scar left by the disease 
may appear centrally when the morbid process is in activity at the 
border, but usually in the latter event the rim is simply made up of 
a reddish ring covered with firmly attached scales. 



Fig. 71. 




Lupus erythematosus of the face (from a photograph of one of the author's patients.). 

Mixed forms occur where all the symptoms described above may 
coincidently or successively appear in one subject. Variations are 
marked in both the vascular and follicular directions. In the latter 
there are seen at times patches exhibiting almost pure types of sebor- 
rhcea faciei. 

The disease is remarkably chronic in its course, lasting in cases for 
a quarter of a century, and throughout not interfering with the gen- 
eral health. So-called " galloping " cases are described by French 
writers usually with the visceral complications described above. 
The disease varies in the subjective sensations it produces ; being at 
times accompanied by excessive itching, and often by no discomfort. It 
is much more common in women than in men, and is a disease of adult 
years. Kaposi reports a single case in one child three years of age. 



586 DISEASES OF THE SKIN. 

The scars left by the affection are indelible and characteristic. 
They are generally uniform and superficial ; can be readily pinched 
up between the thumb and finger; are of a dull, whitish tint, and 
rendered punctate iu a peculiar manner, suggesting the action of the 
engraver's tool in what is known as the " stippling " process. They 
are never pigmented, puckered, radiate, stellate, corded, or deeply 
attached. Very rarely they are seated upon the glans penis. 

Etiology. — Lupus erythematosus is described by some writers as a 
variety of lupus vulgaris. It is, however, not properly so-classed till 
tubercle bacilli have been recognized in its lesions, a position not yet 
reached. Its causes are as yet obscure. 

Much has been said and written to prove that the disease is of 
tuberculous origin, but inasmuch as numbers of tuberculous patients 
in all parts of the world never exhibit traces of the disease, the proof 
has not been obtained. In by far the larger number of patients 
actually displaying characteristic disks of erythematous lupus, the 
usual concomitants of tuberculosis are wanting. In many patients 
careful investigation fails to discover any other evidence of ill health. 
Yet others, chiefly young women after the puberal epoch, suffer from 
the chlorosis, anaemia, and menstrual irregularities common to their 
sex and age. As for tuberculosis, adenopathy, and malnutrition, 
cases of erythematous lupus do occur in subjects affected with such 
symptoms, as has been shown. Considering the rarity of the disease 
and the no less significant frequency of seborrhoea, the wonder is not 
that they should occasionally concur, or be transformed, the latter 
into the former, but that such phenomena are not more conspicuously 
and frequently noted. 

The disease is more common in women than in men, two-thirds of 
the former to one of the latter, usually appearing first in the third de- 
cade of life, in this particular presenting a contrast with lupus vulgaris. 
It may, however, first develop in childhood, middle life, or old age. 

It may follow acne, undue exposure to sunlight, seborrhoea, variola, 
erysipelas, vesication with cantharides, and the traumatism of leech- 
bites. The author has seen it appear where the curette had been 
employed in a patient with a characteristic patch elsewhere on the face. 

Pathology. — The morbid process originates either in the peri- 
glandular tissues of the sebaceous or sudoriparous follicles and their 
ducts, or in some part of the panniculus adiposus ; in other words, 
from any point in the superficial or deep strata of the cutaneous or 
subcutaneous structure. Under the microscope the elements of .both 
the epithelia lining the glands and of the connective tissue without 
are seen to be multiplied and largely commingled with the ordinary 
products of an inflammatory process. 

Thin 1 found enormous distention of the capillaries in the papillae, 
their loops of venules being choked with red blood-disks, and in 
this state almost completely occupying the digitation. The same 
was observed in the peri -follicular plexuses, while yet the rete and 

i Med.-Chir. Trans., 1875. 



LUPUS ERYTHEMATOSUS. 587 

glands were quite unaffected. Such alterations would, without ques- 
tion, ultimately follow as the result of the vascular trouble ; but the 
observations are of interest as lending color to the supposition that 
the primary changes in lupus erythematosus are chiefly vascular. 
Similar vascular dilatations, papillary and peri-follicular, have been 
noted by Kaposi and others as concurrent with structural alterations 
in other portions and appendages of the skin. 

After the new growth is thus formed, moderate elevation of the 
initial macule of the eruption and a thickening of the rim of its cen- 
trifugally developing patches follow. Central resorption or atrophy 
of the same material in the epidermis and corium of such a patch 
explains the wasting and depression so frequently observed in each. 
By the destruction of the glandular and connective-tissue elements 
in the course of retrograde metamorphosis, a loss results which is 
made good by the peculiarly punctate form of the cicatrix which 
results. 

Veiel classes the disease among the superficial inflammations of 
the skin. 

Diagnosis. — The facies of the patient, with lupus erythematosus 
of that region, is usually so characteristic that the disease is there 
recognized with ease. When the hand and other portions of the 
body are involved, the diagnosis is somewhat less readily estab- 
lished. In the former situation the disease has a predilection for the 
dorsum, and invades the palm usually only by extension to it from 
behind. 

From lupus vulgaris it may be recognized by its occurrence 
originally at a later period of life ; by its greater tendency to sym- 
metry ; and by the absence in most cases, of nodules, ulceration, 
and extension in the deeper portions of the skin or underlying 
structures. 

In eczema there is usually some history of moisture ; in ery- 
thematous lupus, rarely. In eczema, also, the itching is a more per- 
sistent and distressing symptom ; but the acuteness of eveu chronic 
eczema, as compared with lupus erythematosus, will suffice to dis- 
tinguish the two diseases. Psoriasis is rarely, if ever, limited to a 
single patch on the face; it is also characterized by more lustrous and 
more readily exfoliating scales. Its patches are, furthermore, uni- 
formly well covered with scales, and of equal flatness in all parts, 
while those of lupus erythematosus are irregularly squamous, the 
scales being often clustered at the orifices of the ducts of the seba- 
ceous glands, while the rim of the patch is elevated and the centre 
depressed. 

In acne rosacea there are marked telangiectases and papulo-pus- 
tules or nodules which are not found in erythematous lupus. In 
tinea circinata there may be a clearing, but never a cicatriform 
centre of the circular disk. The circular serpiginous syphiloder- 
mata of the face occur usually with other manifestations of lues, are 
characterized by a much darker hue of the dense infiltration, and 
in most cases exhibit distinct signs of ulceration. Cicatrization or 



588 DISEASES OF THE SKIN". 

atrophy of the skin without preceding ulceration, is the sign and seal 
of typical erythematous lupus. 

Treatment — The internal treatment of this affection is not highly 
satisfactory. Often none is indicated or required. Anderson l highly 
recommends the trituration of twenty-four grains (1.6) of iodine 
with a little water, adding to this one ounce (32.) of starch, till a 
uniform deep blue, almost black color, is obtained, after which the 
iodide is dried by gentle heat. A large teaspoonful is given in a 
little gruel three times daily. The administration of the iodide of 
potassium, arsenic, and iodoform has also been followed by note- 
worthy results. In general, however, cod-liver oil and the chaly- 
beates will be found most serviceable in connection with such 
hygienic regimen and diet as are in each case specially indicated. 

The local treatment of the patches of disease is of importance. 
Inasmuch as the affection is one whose involution is occasionally 
accomplished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequelae, the simpler measures should 
be first adopted. Of these, green soap, applied as a plaster, or in the 
form of the spiritus saponis viridis, is most serviceable. It not only 
cleanses the patch of its scales, but stimulates the surface, often to the 
extent of inducing a reparative process. The patch may be briskly 
rubbed, either with the soap or the spirit, in combination with hot 
water, after which an ointment may be applied, preferably of sulphur, 
in the strength of two drachms (8.) to the ounce (32.) of petroleum 
ointment. When a decided effect is produced the spirit may be dis- 
continued, and the hot water and unguent for a time employed alone. 
A decided and beneficial effect can be noticed at times after the 
topical application of very hot water alone, sopped on the part for 
twenty minutes at a time with a small sponge mounted on a handle. 

The following is a geutle stimulant : 

M. Zinci sulphat. \ „ . 2 

Potassii sulphuret. / h ' 

Spts. vin. rectif. f ^ iij ; 12 

Aq. rosar. f.^iijss; 112 M. 

Sig. To be diluted as required for external use. [Duhring ] 

The following is a formula for a stronger lotion : 

M. Chrysarobin. Hyss; 10 

Acid, salicylici "> ft& 2 

Calaminis pulv. / d ' 

iEtheris f£j; 4 



Collodiiflex. fgv; 20 

Sig. To be applied with a brush. 



M. 



For this may be substituted pyrogallol, in the strength of half a 
drachm (2.) to the ounce (32.) of salve. 

Other substances for local application are : the tars, iodized 
phenol, iodized glycerin, the iodide of sulphur, iodide of potassium, 
iodine in fine powder and tincture, naphthol, ichthyol, chloracetic 
acid ; salicylic acid three to ten per cent., and resorcin ten per cent., 

i Brit. Med. Journ., May, 1880. 



LUPUS ERYTHEMATOSUS. 589 

each in collodion ; and sodium ethylate (an unsatisfactory prepara- 
tion). Thilanine, lately recommended with some reserve by my 
friend, Dr. George Henry Fox, of New York, has been employed 
by me in six cases. One of these, a male patient with charac- 
teristic follicular disks of the cheek, was very carefully observed 
after a series of applications made by myself with special attention 
to the results. I am confident that this remedy, a combination 
of sulphur aud lanolin, is of value in these cases. Chrysarobin 
aud pyrogallol have a decidedly favorable effect, subject, however, to 
the inconvenience of staining the skin, a prominent objection in the 
majority of cases where the disease is displayed upon the face. Upon 
the hands the author has employed chrysarobin with the effect of pro- 
ducing a typical cicatrix in the course of a month when the disease 
had lasted for two years. 

Erasion by the dermal curette, in accordance with the method pro- 
posed by Dubini, of Milan, and popularized by Yolkmann, of Halle, 
has been successfully practised by many operators ; as also the treat- 
ment by multiple punctures. These have not met with the favor in 
lupus erythematosus which has been accorded them in lupus vulgaris ; 
while multiple incisions by the laucet, or the instrument devised by 
Balmauno Squire 1 have been rewarded with greater success. The 
instrument of the latter makes sixteen simultaneous superficial in- 
cisions in the patch previously frozen by the ether spray. Vidal 2 lay 
stress upon attacking in this way the peripheral zone of the lesions. 

In exceeding obstinate cases, those especially where the elevated 
rim of the erythematous disk refuses to yield to the simple measures 
described, a solution of caustic potassium in distilled water, one part 
to two or four, may be gently applied with a cameFs-hair brush, and 
the alkali immediately neutralized by the addition of dilute muriatic 
acid as soon as the desired effect is produced. That effect, it must 
be remembered, is superficial cauterization only. When the sero- 
sanguineous exudation and reactive effects disappear, the rim is seen 
to be flattened and to have lost in part its violaceous blush. After 
such severe application, which should never be trusted to the hand 
of one unskilled in its use, an anodyne cerate containing morphia or 
opium should be spread over the part. 

Vesication with cantharides, recommended by Anderson, has been 
endorsed as valuable by several authors. The same may be said of 
the mercurial plaster, of which Kaposi speaks highly ; while he and 
others agree that carbolic, salicylic, nitric, chromic, and sulphuric 
acids, the chloride of zinc, the other mercurial preparations, and 
arsenical pastes, are of less value. 

I have used electrolysis with benefit in a few cases, passing the 
needle connected with the negative pole of the battery deeply into 
the involved tissue. Among other useful applications may be named 
pure creasote, white precipitate salve, Unna's gutta-percha plaster- 
mull of pyrogallol, iodoform, and the zinc oxide pastes. 

1 British Medical Journal, May, 1880. - Le Praticien, Nov. 14, 1881. 



590 DISEASES OF THE SKIN. 

Prognosis. — A favorable opinion with respect to the future of the 
disease can never be safely given ; though, as regards the general 
health and comfort of the patient, there can rarely be question. At 
the same time the affection is capricious in its course, and may on 
occasions, after long periods of obstinate persistence, very rapidly 
improve under the simplest treatment. It is liable to relapse, though 
not to frequent recurrence. Its tendency to the production of persist- 
ent scars should always be remembered in formulating a diagnosis. 

Ainhum, from a native term, meaning " to saw." This disease 
was first described by Dr. J. F. Da Silva Lima, of Bahia, in Brazil. 
In a paper by this observer, which was read by me before the Ameri- 
can Dermatol ogical Association, in 1880, the disease was described as 
affecting usually the little toe of the negroes resident both in Africa 
and Brazil. An indurated ring encircled the root of the digit, which 
produced, finally a deep, narrow circular depression, the latter deep- 
ening till the toe was strangulated, and finally, in the course of from 
five to ten years, completely detached. Meantime the volume of 
the digit was greatly increased by development of fatty tissue at the 
expense of the tendons, vascular elements, bones, and cartilages. 

This paper was accompanied by the presentation of a toe affected 
with ainhum ; and the specimen was referred to a committee, who 
examined it with care, and reported the result of the examination 
the succeeding year. The report, presented by Dr. Heitzmann, of 
New York, after giving a full description of the anatomical appear- 
ance of the specimen, suggested the probability that the constricting 
ring was produced artificially by tying a thin ligature around the toe, 
which, if not continuously encircling it, was worn at least for long 
periods of time. 

Duhring also has published the report of a case of ainhum where 
microscopical examination was made by Dr. Wile, of a toe which 
was cast off from the foot of a negro in West Virginia. The latter 
came to the conclusion in this case also that the disease was essen- 
tially an inflammatory oedema produced by ligating the toe. 

Later, Roux (Traite prat, des Malad. des Pays Chauds, t. iii., 
Paris, 1888) and Eouget (These de Paris, 1889) with Trelat, Eyles, 
and others have further studied the disorder. None seems yet to 
have disproved the fact that among superstitious races, especially 
the blacks, the most singular practices of self-mutilation are observed ; 
and the enormous probability that in these cases the toe is constricted 
by a ligature intentionally applied around it, has not yet been set 
aside. 

The affection is still, however, described as a special disease of the 
toes, noticeably never congenital nor affecting any but adults. 

It evidently has no relation with sclerodactylie, scleroderma, nor 
to spontaneous amputation of members due to mutilating disease. 
The histological evidence, in the many cases examined, discloses no 
process save that producible by constriction ; rarefying osteitis, hyper- 
plasia of the skin and all other tissues in advance of the constricting 



SYPHILODERMA. 591 

ring, endarteritis obliterans, and gradually resulting fatty metamor- 
phosis. 

Incision of the constricting ring at an early period is said to 
relieve the disease. In most of the cases amputation is required or 
is effected by the natural progress of the disorder. 



Syphiloderma. 

Gr., oic, and ol/.oc, a companion of swine : a term coined for poetical 
purposes by Fracastor. 

Statistical frequency in America, 11.22. 

Syphilis is a chronic infectious disease, transmitted by heredity, or by the 
medium of intoxicated blood or morbid secretions, capable of involving in 
its course any one of the organs and tissues of the body, whose manifesta- 
tions in the skin are termed syphilodermata. 

Syphilis is a disease not yet actually demonstrated to be produced 
by micro-organisms, but whose position among the infectious granu- 
lomata is now practically established. It is true that Lustgarten, 
Doutrelepont, and others, have demonstrated the presence of bacilli 
resembling those found in tubercle, in papules, nodes, chancres, and 
secretions from syphilitic lesions ; but the strict requirements of 
science as to the proofs of etiological value in these particular germs 
have not yet been fully satisfied with respect to this disease. Whether 
these micro-organisms or others be finally demonstrated to be the 
potent agency in producing syphilis when it is transmitted by the 
medium of a virus, it is at least certain that the revelations made 
by late investigations into the nature of lepra, mycosis fungoides, and 
tuberculosis lend the very strongest support to the doctrine that the 
contagium of syphilis is due to the presence in its secretions of a 
species of bacterium. 

Syphilis has been described by one writer as an " imitator of other 
diseases." Whatever exception it is proper to take to the doctrine 
implied by such a term, it is necessary to understand clearly of the 
manifestations of the disease that they are protean in character, and 
may occur in every organ and tissue of the body. These manifesta- 
tions are both like and unlike the symptoms of non-syphilitic disease 
of such organs and tissues. It would be, therefore, more in accord- 
ance with facts to describe syphilis as a special mode of disease. Its 
phenomena differ from other pathological phenomena, chiefly in the 
syphilitic modality with which they are impressed. After infection 
there is a different behavior of the living matter or protoplasm of 
which the body is constituted. Its mode is thenceforward tempo- 
rarily changed as regards the processes of disease. Hence the 
importance of recognizing this modality in relation to disease of the 
skin, and of ascertaining the limits within which this influence is 
both originated and exhausted. 

Ricord, of France, was first to classify the phenomena of syphilis 



592 DISEASES OF THE SKIN. 

as they develop in three distinct stages. In the first, or primary 
syphilis, were included the symptoms relating to the chancre and its 
accompanying adenopathy. In a second stage, lasting from the date of 
the onset of general syphilis during a period of about two years, 
were grouped symptoms that were as a rule superficial, symmetrical, 
and more or less transitory. In a third, or tertiary stage, the symp- 
toms included were, as a rule, asymmetrical, more profound, involving 
the subcutaneous and deeper tissues ; invading often not merely the 
skin but the osseous, cartilaginous, and other structures of the body, 
including lesions of the viscera. This simple scheme of the great 
syphilographer when first given to the scientific world revolutionized 
all previous conceptions of the disease, and has dominated the medical 
world up to the present time. 

But there are objections to its continued acceptance, based largely 
on its incompleteness. The distinctions it seeks to make are wholly 
artificial, and are defined by poor limits ; and are so often completely 
violated that they fail to explain the most important of accidents. 
To be consistent and to explain in part the violations of their time- 
schedule, the French have had to coin such phrases as " precocious," 
" tardy," " galloping," etc. Further, the mind once dominated by 
this scheme was educated to look for the evolution of symptoms 
within each of these artificial stages in a determinate order, e. g., 
after the occurrence of macules, papules ; after these, pustules, tuber- 
cles, etc., a progression rarely observed in any given case. 

The symptoms of syphilis are better studied as they are clinically 
displayed in distinct departures from the infection moment along 
lines which are not fixed, but where are intermingled symptoms with 
varying shades of severity. The four chief classes which may thus 
be recognized include most of the clinical pictures of syphilis : 

I. Benignant Syphilis, with Superficial and Transitory Symptoms. 
Here the skin lesions of general syphilis are few and at times even 

insignificant. A macular rash, for example, over the surface of chest 
and belly, lasting for a few days or a week or more, accompanied by 
ganglionic enlargement, after involution, leaves the patient for the 
remainder of life free from obvious signs of the malady. These 
instances are rare. 

II. Benignant Syphilis, with Superficial and more or less Per- 
sistent Symptoms. 

In this class are to be catalogued most cases of the disease. Some 
relapse to it from the class previously described ; others, fewer in 
number, retrograde to one of the groups named below. There is 
throughout no cachexia, and the skin symptoms of the affection are 
neither destructive nor deep. Their chief significance lies in the fact 
that they may persist or recur till the disease, either as a result of 
treatment or of a decline due to other causes, ceases to manifest itself 
by any symptoms whatever. 

III. Malignant Syphilis, with Profound, Relapsing, or Persistent 
Symptoms that ultimately resolve. 

In this group are- collected the cases in which, with persistent or 



SYPHILODERMA. 593 

recurrent symptoms gradually involving the deeper structures of the 
body, the system suffers to the extent of exhibiting the sigus of 
cachexia. Patients in this class are, by reason of efficient treatment 
or the reverse, readily transferred both to the class last described and 
the fourth. 

IV. Malignant Syphilis, with Profound and Relapsing or Per- 
sistent Symptoms that are ultimately destructive. 

In this are included the gravest forms of the disease ; those exhib- 
iting deep and destructive cutaneous lesions ; those implicating the 
viscera and bones, with other structures ; those interfering with the 
integrity of the organs by reason of either atrophic or degenerative 
changes set up after a circumscribed or gummatous involvement of 
tissue. 



Ko one of these groups of symptoms necessarily follows any other. 
The last described may occur within a few months after the appear- 
ance of so-called primary syphilis, even though formerly included in 
the old nomenclature among those of late, or tertiary, type. Many 
cases, indeed, of grave syphilis are of the type described by the 
French as " precocious," that is, develop symptoms of gravity either 
before the healing of the chancre or soon after. 

Every attack of acquired syphilis acknowledges for its first symp- 
tom an infecting chancre ; and every infecting chancre signifies 
syphilis. 

Chancre. — A chancre is that modification of the sound or patho- 
logically altered skin or mucous membrane, preceded by a period of 
incubation, characterized by sclerosis, and accompanied by adenopathy, 
which constitutes the initial lesion of inevitable syphilis. 

Chancres usually appear upon or about the genital organs simply 
because those organs are most often exposed to the disease. They 
may, however, occur upon any portion of the surface of the body. 

They appear after a period of incubation, an interval of time 
between the date of exposure to the disease and the manifestation of 
its first symptom. This period averages in length twenty-one days, 
and may extend from ten days to two months and even more. 

The chancrous modification may, as stated above, involve the 
normal or pathologically altered skin or mucous membrane. Upon 
previously sound surfaces, chancres may appear, after the incubative 
period, as maculae, papules, tubercles, erosions, fissures, or ulcers, each 
of which, at some future period of its history, is characterized by a 
peculiar hardness of the tissues about and beneath the lesion, this 
condition being known as the initial sclerosis. These symptoms vary 
according to the location of the lesion and the friction or other 
external treatment to which it has been accidentally subjected. Gen- 
erally it may be said that they all tend to the papular type, the 
macule developing into that lesion, the tubercle being evolved from 
its exceptional enlargement, the ulcer from its degeneration, and the 

38 



594 DISEASES OF THE SKIN. 

erosions or fissures from the accidents of its less pronounced features. 
Occurring upon mucous or quasi-mucous surfaces, these lesions are 
influenced by heat, moisture, and friction (labia, prepuce, etc.) Here 
the superficial erosions are usually circular in outline, are very 
slightly depressed, and rest upon delicate beds of sclerosed tissue, the 
so-called parchment induration. The papule is often represented by 
a macular discoloration of the membrane, tolerably well circum- 
scribed, where coarse examination would scarcely suggest elevation of 
the surface, with a sclerosis of no greater extent than that of the 
erosion with which it probably sustains a close relation. As a result 
of heat, moisture, and friction, however, the typically dry and scaling 
papule constituting the chancre of the integument, is here rarely 
encountered. More often, the lesion is a circumscribed ulcer with 
clean-cut walls, penetrating deeply to the derma or even below it, 
with a scanty secretion and reddish floor, resting upon a split-pea 
sized mass of sclerosed tissue. Other usual forms are superficial 
erosions, in themselves of insignificant aspect, surmounting large 
nodules, tubercles, or even long linear ridges of densely sclerosed 
tissue, undergoing repair or degenerating according to the coudition 
of the patient and the treatment to which he has been subjected. 
These erosions are usually out of all proportion to the size of the 
indurated mass upon which they rest. Such voluminous indurations 
are occasionally perforated by deep conical or funnel-shaped ulcera- 
tions of formidable aspect, to which the name " Hunterian chancre" 
was once applied. 

Occurring upon cutaneous or mucous surfaces where there has been 
a previous pathological condition, the syphilitic mode is impressed 
upon the symptoms significant of such previous disease. This acci- 
dent is sufficiently common, and the resulting lesions as different as 
those of different diseases. Thus a man or woman may be infected 
with syphilis at the site of an herpetic vesicle upon the lip or genitals, 
such vesicle being unbroken and recent, or several days ruptured; or 
at the site of a balanitis ; or of a vegetation ; or of the soft con- 
tagious sore of the genital region best recognized in America under 
the term " chancroid." Or the inoculation may occur at the site of 
a traumatism, as for example where the frenum is slightly torn in 
coitus, or where the bruised knuckle of the accOucheur is exposed 
during the practice of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short- 
lived, persistent, or recurrent ; and in this respect resemble the 
chancre itself, which may endure but for a few days, or be in course 
of full evolution at the date of appearance of the so-called secondary 
symptoms. 

With very rare exceptions, the ganglia in anatomical connection 
with the chancre become, as a consequence, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy; with labial chancres, submaxillary adenopathy; with 
chancres of the lid, pre-auricular adenopathy, etc. The glands usually 



SYPHILODERMA. 595 

enlarge within a few days after the appearance of the chancre, and 
remain in that condition for several months afterward. They are 
indurated, on one or both sides of the body ; are freely movable ; are 
unattached to surrounding tissues; are neither painful, tender, nor 
inflammatory ; and hence neither terminate by suppuration nor ulcer- 
ation. 

It will thus be evident that the word " chancre" is applicable only 
to certain features assumed by other lesions ; and is not itself descrip- 
tive of a lesion differing absolutely from all others. It is indeed 
clear that there can be no particular chancre lesion, since in turn the 
macule, vesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, 
and fissure may each become a chancre. Every other elementary 
lesion of the skin, therefore, may assume the chancrous features, in 
other words, display in its disease-process the modality of syphilis. 
These chancrous features are : infection ; sclerosis after an incubative 
period ; coincident or consequent adenopathy (sclerosis of neighboring 
ganglia) ; and, after a second incubative period, the occurrence of the 
symptoms of general syphilis. The last named is of course an his- 
torical feature, not recognizable during the greater part of the life of 
most chancres. 

Their minor features are less constant and trustworthy. Chancres 
of the skin are often deeply pigmented. Some are painful from the 
occurrence of inflammation. Some are injured by traumatism 
(chancres of nipple in nursing women) ; some, by irritants (caustic 
improperly applied) ; some finally are so insignificant in feature 
(chancre of the vagina) that even the expert is readily deceived in 
their recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a so-called 
second period of incubation. This extends usually from between 
the end of the first to the end of the second month after the appear- 
ance of the chancre, the average being between the fortieth and forty- 
fifth days. During this period the general condition of the patient 
is one which, by subjective and objective phenomena, displays signals 
of the approaching distress of the economy. There is anaemia, and 
even in cases, chloro-anaemia, wandering pains, substernal or about 
the articulations, a cachectic look, engorgement of the superficial and 
deep ganglia, occasionally a well-marked febrile process, the so-called 
syphilitic fever, and, as Bumstead has shown, a special irritability of 
the skin and mucous membranes. 

The so-called periods of incubation in syphilis do not, however, 
really exist. The words used to define them refer to periods of time 
in which, upon gross inspection, the evolution of the disease does not 
seem in progress, but when there is ample evidence that in place of 
an u incubation " there is a gradual involvement of one portion of 
the body after another. Thus, in the second incubative period of 
the text- books, it is evident on careful examination of the patient 
about to display the external manifestations of systemic disease, as 
suggested above, the symptoms are by no means latent. The glands 



596 DISEASES OF THE SKIN. 

of mauy parts of the body outside of those in the vicinity of the 
initial sclerosis become tumid and at times painful, including the 
tonsils and thyroid gland. The skin may exhibit icteroid symptoms 
as a result of hepatic disturbances ; the excretion of urea may be 
augmented or albumin may appear temporarily in the urine; pains 
in the head, limbs, and other parts of the body may produce distress 
even of a severe grade ; the leucocytes may relatively increase in 
number; the joints become painful and swollen; and muscular con- 
tractures with many other evidences of a morbid state of the system 
may indicate to the careful observer that a general process of intoxi- 
cation is in more or less development. 

At this moment the " second period of incubation " of the disease 
being completed, the patient is ready for an " explosion " of general 
syphilis. Insidiously or suddenly, first noticed upon the skin beneath 
the clothing, with rapid efflorescence over the entire surface after a 
hot bath, the stimulus of liquor, or the excitement of the dance, 
appear the syphilodermata, or syphilides, the skin symptoms of 
syphilis. 

Syphilodermata. 

The skin manifestations of syphilis are of common occurrence; 
numerous as to their forms, and of the greatest importance from a 
diagnostic point of view. 

As in syphilis of other organs, that of the skin is betrayed in 
symptoms like and unlike those of non-syphilitic affections. The 
study of these differences is here also a study of the syphilitic mode 
of disease. In a treatise of this scope and within these limits it will 
be proper to describe chiefly those evidences of the syphilitic process 
to be recognized in the integument. 

Lesions of the skin appear in syphilitic individuals of both sexes, 
in all periods of life, and in all stages of the disease. They are, 
however, much more frequent during the first two years after infec- 
tion, subsequent to which period the symptoms of the disease are 
more commonly betrayed in subcutaneous lesions, or those which 
affect the viscera, the osseous, nervous, muscular, "and vascular sys- 
tems. 

General Characteristics of the Syphilodermata. — The 
syphilodermata, like chancres, are, properly speaking, modalities of 
such symptoms as occur in diseases not syphilitic. The distinctive 
difference between the papules, ulcers, and other lesions of syphilis 
and lupus for example, is a difference chiefly in their mode of evolu- 
tion and involution. It is the syphilitic behavior, rather than the 
syphilitic lesion, w T hich guides the diagnostician to his end. The 
syphilides, in short, resemble the lesions of most of the other diseases 
of the skin, and differ also in various degrees from each one of the 
latter. Hence is seen the importance of a clear recognition of their 
general characteristics : 

Absence of subjective sensation. The eruptions produced by 



SYPHILODERMA. 597 

syphilis are rarely attended by itching, burning, or painful sensa- 
tions of any sort. This is frequently a positive aid in establishing a 
diaguosis, and, as a rule, is the more valuable the graver the lesion. 
Great difference, however, will be noted in this respect between 
different individuals. Occasionally considerable itching will be per- 
ceived, and syphilitic ulcers, especially of the leg, will be productive 
of severe pain. At the same time, it is a common experience to find 
a patient quite tranquil as regards all subjective symptoms, covered 
from head to foot with a brilliant macular syphiloderm, or exhibit- 
ing, with the utmost composure, an enormous number of serpiginous 
ulcerations on his scalp and extremities. 

Polymorphism, multiformity of lesions, a term used to desiguate 
the coincident appearance of lesions of various types upon one indi- 
vidual, is true of syphilis as of other diseases, such as lepra and 
scabies. Viewing the cutaneous and other lesions of syphilis as a 
whole, this feature is strikingly significant, as it is possible to observe 
at one and the same time upon the person of a single infected indi- 
vidual, symptoms indicative of pathological changes in the skin, 
mucous membranes, hair, nails, lymphatic glands, and periosteum. 

To a less marked degree, this is true of the syphilodermata. The 
type of the syphilitic skin lesion is generally papular; and such 
lesions may originate from macules, enlarge into tubercles, or degen- 
erate into ulcers. The simultaneous coexistence of several of these 
forms is ofteu due, as Bumstead and Taylor have well shown, to 
their chronicity, their tendency to recurrence, and the changes which 
they undergo. 

Career. The historical course of the syphilides suggests certain 
common features. They are rarely accompanied by local inflamma- 
tion, and with the exception of the syphilitic fever, are usually 
unattended with pyrexia or malaise. The tolerance by the general 
economy of an extensively developed syphiloderm, is highly signifi- 
cant of the disease. Again, syphilis, though generally described 
as a chronic disease, is, judged with respect to time merely, much 
more acute than several others. The syphilides have a distinct 
career, pursuing, even when untreated, a natural process of evolution 
and involution. Few, save those upon the lower extremities, where 
the force of gravity is an important element in the fixation of all 
local disease, persist iu unvarying type for any lengthened period of 
time. One lesion is apt to succeed another by development or 
degeneration ; and many of the untreated syphilides disappear with- 
out leaving relics of their existence upon the surface of the skin. In 
these last named particulars, syphilitic cutaneous manifestations are 
singularly different from lupus and carcinoma, for example, where 
the lesion is usually of one type, and persists in one location for a 
long period of time, during which the syphilide which it resembles 
would have progressed either to much more extensive damage or 
permanent repair. 

Color. There is no color peculiar to the syphilodermata which 
may not be seen in other diseases of the skin. It is important to 



598 DISEASES OF THE SKIN. 

recognize the fact clearly, as there are those who claim to diagnosti- 
cate the syphilides by their hue alone. The color, however, consid- 
ered in connection with the other features of the syphilides, is highly 
characteristic, and often sufficient to enable one at a glance to identify 
the nature of the disease. These color shades are usually less bril- 
liant than those seen in other cutaneous diseases, and possess less of 
the scarlet and crimson quality. They are admixtures of red, yellow, 
and brown, in various proportions, with a frequent slight preponder- 
ance of the brown. They have been compared to the color of raw 
ham and copper, terms which have been unfortunately so associated 
with the hue of the syphilides that the non-recognition of such 
peculiarity has led to many errors in diagnosis. Pigmentations, in 
various shades of chocolate, coffee, and black, are recognized among 
the syphilides both during their evolution and after completion of 
their involution. The process, as in cases where there has been no 
luetic affection, is here also due to increase of the pigment in the 
part, both with and without the extravasation of blood. Recent 
syphilitic scars are usually pigmented both in centre and periphery. 
Here also it is not so much the color, as the scar ivith the color which 
gives special significance to such lesion-relics. 

Contour. The contour of single elementary cutaneous lesions in 
syphilis, as also of a group of aggregated lesions, is usually either 
circular, or has a distinct tendency to assume such a configuration. 
Thus it is common to find outlines of patches, ulcers, and scars 
observing the curve of a segment of a circle; and coalescence of 
several such tends to produce the serpiginous aspect. Figures re- 
sembling the horse-shoe, the kidney, the half-moon, the letter S, and 
the dumb-bell are thus produced. The earlier exanthems of syphilis are 
usually symmetrical; the later, asymmetrical. Even the symmet- 
rically distributed eruptions will at times occur in annular patches, 
made up of maculo-papular lesions arranged in a circular or crescentic 
line. Patches of syphilitic eruption will often clear up at the centre 
and develop or spread at the circumference of a circle. 

Site. No portion of the integument is free from the possibility 
of invasion by syphilis. It may involve at once almost the entire 
integument, or spread rapidly from point to point, having covered 
finally a large area, or appear conspicuously at distant and isolated 
points of limited extent, or, finally, be exclusively manifested in an 
insignificant lesion or group of lesions, ephemeral in course, and 
limited to one portion of the body. 

The site of a syphilitic eruption may be determined apparently 
by the capriciousness of the disease, and yet result from local irrita- 
tion of the skin of infected individuals. The accumulations on 
the napkins of women invite the occurrence of labial condylomata; 
the lips of the infant, after contact with the nipple of the mother, 
become the seat of rhagades and fissures ; while the tongue of the 
tobacco-chewer and the fauces of the tobacco-smoker acknowledge 
special sources of mischief. 

There are some sites of preference for special lesions, as, for 



SYPHILODERMA. 



599 



example, the squamous syphiloderm of the palms and soles, and the 
papules of the forehead, constituting the so-called "corona Veneris." 

Amenability to treatment. Mercury possesses a singular influence 
upon the syphilodermata, which is promptly perceived when the 
drug is administered internally. This singularity rests upon the 
broad fact that the lesions of many other cutaneous diseases not only 
refuse to acknowledge the benefit of such medication, but in many 
cases are aggravated by it. The importance of clearly recognizing the 
character of each cutaneous disorder submitted to treatment, is thus 
well illustrated. 

Characters of certain 'particular lesions. Certain families of lesions 
in syphilis exhibit characteristic features. Thus some papular lesions 



Fig. 72. 




Facial cicatrices of tubercular syphilodermata after twenty-five years of infection. (From a 
photograph of one of the author's patients.) 

are surrounded at the base by a peculiar fraying of the epidermis, 
in consequence of which they are encircled by a little fringe of 
scales resembling a collar. The scales of syphilis are usually not 
abundant, but fine, dirty-whitish in color, or occasionally brownish. 
The crusts of syphilis are apt to be bulky, greenish-black in hue, 
and to surmount secreting ulcers of various depths. Such ulcers are 
generally circular, or exhibit in contour a tendency to assume the 
circular line, while the cicatrices by which they are succeeded have a 
similar configuration. The scars of syphilis are frequently smooth, 
delicate, very slightly depressed, unattached to subjacent tissues, and 



600 DISEASES OF THE SKIN. 

pigmented. Lastly, from several of the secreting lesions of syphilis, 
especially those upon and about the ano-genital region, proceeds a 
discharge having an offensive odor, and capable of communicating 
the disease to a sound individual by inoculation. 

Subjection to external agents capable of exerting an influence upon 
non-syphilitic eruptions. It is an obvious error to conclude that the 
exanthemata of syphilis are produced exclusively by the operation of 
a systemic intoxication. Many of the pustular syphilodermata are the 
result solely of pyogenic cocci ; and their extension may be by inocu- 
lation and auto-inoculation. This is shown not merely by the ordi- 
nary methods of demonstration, but by the clinical fact that these 
lesions are far more numerous among the filthy, the neglected, and 
the ignorant. Often syphilodermata are commingled with sebor- 
rheic and eczematous affections. It is not rare to find patients 
applying for relief in clinical practice who exhibit lesions of syphilis 
commingled with traces of the incursions of lice and bugs, urticarial 
wheals, scratch -marks, and forms of keratosis pilaris, due to the un- 
washed condition of the skin. 

Syphiloderma Maculosum. 

The cutaneous lesions of syphilis, limited to color changes in 
more or less circumscribed areas of the skin, are exhibited in two 
distinct forms, due respectively to anomalies in blood and pigment 
distribution. 

(a.) The Macular Syphiloderm due to Hyperemia is 
termed by several authors the Erythematous Syphilide, or 
Syphilitic Roseola. It is the earliest expression of cutaneous 
syphilis, and is more or less constant of occurrence, differing in this 
respect from several of the other syphilides. It is often unnoticed 
by the patient, whose attention may be first called to it after its 
recognition by the skilled eye of another. It occurs in coffee-bean 
to filbert-sized maculae, roundish, oval-shaped, or of irregular contour, 
varying in color from a light rosy to a dull mulberry hue. In some 
cases, these markings of the surface are very iudistinct, requiring for 
their recognition the closest scrutiny in a clear light, and occasionally 
even then leaving uncertainty in the mind of the expert. At times 
they constitute an irregular "marbling" of the surface, of a kind 
which renders it difficult to define with the eye the individual lesions 
of which the eruption is composed, while the general visual effect of 
the exanthem is exceedingly distinct. They are not elevated above 
the general level of the integument, but may change in type, a 
papular lesion developing later in the same site. 

Like all maculae of the skin due to vascular changes, they vary in 
color with the complexion of the individual, with the time which 
elapses after their first appearance, and with vascular changes in the 
superficial plexus of bloodvessels. Thus the deeper shades are 
usually observed in thick and muddy-tinted skins; the more delicate 
upon the breast, for example, of blonde women. The eruption 



SYPHILODERMA. 601 

usually appears between the sixth and eighth week after the appear- 
ance of the initial sclerosis, and, when untreated, develops for about 
one week more. It persists for a variable period of time, depending 
upon the severity of the constitutional disorder and the treatment to 
which the patient is subjected. Daring the early part of this time, 
the hue of the lesions is lighter, and they may be made to disappear 
under pressure ; later, they are more deeply stained, and, exudation 
having occurred, the color of the spot does not disappear under the 
finger. When involution is in progress there is slow disappearance 
of all symptoms of the eruption, which fades gradually from view. 
The vascular changes in the capillaries, occasioned by cold, heat, and 
rapid cardiac contractions, all influence the eruption to a marked 
degree. A hot bath, a dance, a glass of spirits, a fit of excessive 
coughing, laughter, etc., may all bring the lesions into prominence. 

The eruption may be limited to the skin of the belly, extending 
also sparsely over the chest, loins, ano-genital region, and thighs, the 
palms, soles, forearms, and legs, or, in exceptional cases, profusely 
cover the entire surface of the body (face, ears, dorsal surfaces of the 
hands and feet, and skin of the penis with the progenital region). In 
the milder forms, it is evidently susceptible to external irritation of 
the skin, as it is common at the wrists where a starched cuff is worn, 
over the brow in the line covered by the hat-baud, and particularly 
well developed in men where the trousers are "reinforced" (peri- 
neum and inner faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is preceded 
by a febrile state, with marked amelioration of symptoms when the 
rash is fully developed; while again it is throughout accompanied 
by slight rise in the temperature, the patient having the so-called 
" bilious" appearance, muddy complexion, coated tongue, icteroid 
hue of conjunctivae, and offensive condition of the breath. Wander- 
ing pains in the extremities, and especially beneath the sternum, 
are frequently experienced. The last mentioned is highly significant, 
and the whole is probably due to the effect upon the nervous system 
of the circulation of the recently intoxicated blood. These pains are 
not those produced later in periosteal and other complications of the 
disease, and are the more significant as the eruption itself is produc- 
tive of a scarcely appreciable subjective sensation. The superficial 
ganglia of the body are usually engorged at the same time; the 
fauces congested ; the hairs of the scalp slightly loosened in their 
follicles, and, in the latter region, in severe cases, papules, and pus- 
tules may form. Inasmuch as the order of sequence of phenomena 
in syphilis is subject to a singular inversion, it occasionally happens 
that there is concomitance of later signs of the disease, such as iritis, 
affection of the nails and bones, or even, in places, pustular, papular, 
and squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This is a point of considerable importance. The 
physician should never conclude the examination of a patient com- 
plaining of suspicious genital lesions without carefully exploring the 



602 DISEASES OF THE SKIN. 

surface of the trunk, aud also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where 
an initial sclerosis may exist. In a diagnostic and therapeutic sense, 
the information thus gained may be precious, and in a large propor- 
tion of all cases is of a kind quite hidden from the knowledge of the 
patient. 

Relapses occur in certain cases with limitation of the disease to 
parts previously affected or unaffected. At the end of the first 
twelvemonth, recrudescence of larger maculae in annular groups may 
occur. Exceptional forms are noted where darker puncta appear in the 
macular lesion, occasionally traversed by a hair. These are localiza- 
tions of a more intensely hypersemie or exudative condition about the 
orifices of the ducts of the follicles. 

The diagnosis of this syphiloderm is readily established, in view 
of its essentially symptomatic character. From scarlatina, measles, 
and rotheln, it differs in the indolence of the rash, the absence of 
decided elevation of temperature, and the order of its appearance in 
different portions of the body, as it rarely occurs first upon the face. 
Urticaria and the rashes induced by the ingestion of copaiba and 
other medicaments, are distinguished by the marked itching of the 
surface and their very general diffusion over the entire body rarely 
observed in the syphiloderm. Tinea versicolor, usually limited to 
the anterior surface of the trunk, is characterized by a fawn- to 
chocolate-tinted color, by the existence of the readily recognized 
vegetable parasite upon the scales scraped from the surface, and by 
the furfuraceous desquamation which the patient usually describes as 
most noticeable after a hot bath. It is, moreover, of much longer 
duration, aud never extends to the exposed parts of the body, the 
face and hands. Ringworm of the skin of the body is not sym- 
metrical, and is also a parasitic disease. 

All these distinctions, however, are not to be compared for a 
moment in their diagnostic value with the concomitant symptoms of 
syphilis, which are very generally present, such as adenopathy, per- 
sistence of the initial sclerosis, and evident involvement of other than 
cutaneous tissues. 

Such concomitant symptoms will be found occasionally with a 
non -syphilitic eruption due to drugs ingested for relief of the infec- 
tious disease. The most common of these is the iodide of potas- 
sium ; and the eruptions it produces are frequently found both com- 
mingled with the macular syphiloderm and occurring on the eve of 
the appearance of the latter. The existence of acneiform lesions 
upon the face, neck, and posterior surface of the trunk, a vivid 
erythema of the forearms, including the hands, and purpura-like 
maculations of the face, legs, and feet, should never mislead the 
physician as to the character of the disorder with which he is con- 
fronted. It is undeveloped syphilis with a dermatitis medicamentosa 
of the surface. Suspension of the iodide, which fortunately is not 
required in the immense majority of all such cases ; the use of a 
properly selected mercurial, or even (and this is often wise) absten- 



SYPHILODERMA. 603 

tion from all medication, will be succeeded by disappearance of the 
cutaneous lesions, which may be followed later by a mild macular 
syphiloderm, altogether insignificant in comparison with the eruption 
artificially induced. 

(b.) The second form of Syphiloderma Maculosum is that 
due to Anomalous Distribution of Pigment, described by 
authors under the title of the Pigmentary Syphilide. The erup- 
tion, if such it may be called, is occasioned by the appearance upon 
the surface of irregularly circular, usually poorly defined, dirty 
brown and chocolate-tinted maculae which, as they are entirely 
unconnected with vascular changes, do not disappear under pressure. 
The lesions occur as sparse and well isolated discolorations or, more 
commonly, as forming by a species of confluence an irregular rete or 
network, with relatively large interspaces characterized by an absence 
of such color. The eruption is most common upon the sides of the 
neck, especially in blonde women, though it may more rarely involve 
the surface of the trunk and the extremities. It is also most fre- 
quent during the first year after infection, though it may develop 
later. 

It occurs : (a) as a sequel to a macular or maculo-papular syphilo- 
derm over the parts described above ; (6) also, ab ork/ine, as a pig- 
ment disorder, probably under the same influences as those produc- 
tive of the chloasmata of symptomatic origin (chloasma uterinum, 
cachecticorum, etc.) 

According to Fox, of New York, the color changes observed in 
the skin are explained by the occurrence : first, of pigmentary deposits 
chiefly at the centre of the ordinary macular or papular syphiloderm; 
second, of peripheral absorption of such pigment with possible per- 
sistence at the centre of the lesion for a variable time ; third, of total 
absorption of all pigment from the original lesion ; and lastly, of 
peripheral hyper-pigmentation of the spaces intermediate between the 
original maculae. 

The eruption is an epiphenomenon of the syphilitic process, being 
not amenable to the treatment under which other macular syphilo- 
dermata speedily disappear. It is of rare occurrence ; and in the 
cases where I have had the opportunity of studying its features, 
seemed to be an expression rather of general deterioration of the 
health of the skin than of specific disease. 1 

It is liable to be mistaken for that condition in which there is 
simply an accumulation, upon a somewhat greasy skin, of secretions 
and dust, to be seen upon the integument long unwashed. Tinea 
versicolor has a more yellowish or fawn-colored tint, and is more 
abundantly developed upon the front of the chest than the neck. 
Neither vitiligo nor leucoderma is symmetrically disposed, as is 
usually the pigmentary macular syphiloderm. 

1 The author has seen, this eruption most perfectly developed upon the skin of Chinese 
patients affected with syphilis. 



604 



DISEASES OF THE SKIN. 



Syphiloderma Papillosum. 

The type of all cutaneous lesious produced by syphilis is to be 
recognized in the papule. Most of the others are either developed 
from it, transformed to it, or by reversion or admixture, confess that 
the neoplasm of syphilis in the skin is essentially a more or less solid 
circumscribed cutaneous lesion, varying as to size and history. 

Papules, occurring in syphilis, may appear as the first cutaneous 
evidence of infection, or may be developed from earlier maculae. 
They may be small, acuminate, flat, large, disseminated, or in groups. 

Small Acuminate Papular Syphiloderm. — In this eruption 
the lesious are millet- to hemp-seed sized, circumscribed, globular, 



Fig. 73. 




Syphiloderma papillosum. (After Jullien.) 



acuminate, reddish and salmon-reddish, firm elevations of the surface, 
or minute nodules upon the skin, generally symmetrically developed, 
often over the entire body, closely set together and occasionally 
grouped in crescentic figures. When viewed with care, a minute 
vesicle, pustule, or scale may often be detected at the conical apex of 
each lesion, which rarely develops to such an extent as to become a 
characteristic feature of the eruption. The color is at first, especially 
in blonde skins, a species of salmon and red, mixed ; later, the 
darker and browner shades appear. When generalized, the eruption 



SYPHILODERMA. 605 

is well developed, especially over the posterior face of the body, the 
occipitocervical and scapular regions, the buttocks, and calves of 
the legs, though it is often distinct about the anus and genitalia. 
Like several other of the syphilodermata, its earlier are more sym- 
metrical than its later manifestations, whether these be tardy, or 
relapsing, or both. The involution occurs by resorption of the 
plastic exudate, minute and usually scanty, dirty-whitish, colored 
scales encircling the base of each lesion. \Vhen the eruption has 
proved especially persistent, marked pigmentation follows in the form 
of brownish-red blotches, the centre of each of which displays a 
cicatriform relic in the form of a punctum. 

The eruption is often first noticed about the forehead, nose, mouth, 
and neck, localities commonly subject to topical irritation. Thus 
about the forehead in men, the papules will be frequently arranged 
along the band pressed by the lining of the hat ; and the frequent 
fingering of the face, shaving, and irritation by the edge of the collar 
of the shirt, may determine a more speedy efflorescence in the sites of 
contact. About the mouth, tobacco plays the part of an excitant ; 
and about the nose, a localized seborrhoea may be added to the syphi- 
litic phenomena, in which case the lesions may be covered with thin, 
greasy crusts. The eruption is common during the first six months 
after infection, and is usually fully developed after a fortnight when 
no treatment has influenced its evolution. AVhen the lesions are per- 
forated by hairs, they suggest, on superficial examination, a resem- 
blance to keratosis pilaris, and when aggregated in patches of distinct 
contour they might be confounded with psoriasis or squamous eczema. 
But in every case the general physiognomy of the disease may well be 
trusted for the establishment of a diagnosis, having in mind the color, 
the absence of intense pruritus and serous exudation, the disposition 
over the body as a whole, or in portions widely separated, and the 
rarely failing concomitant evidence of syphilitic infection. 

Large Acuminate Papular Syphiloderm. — Lesions of the 
character just described occasionally develop to an unusual degree, 
attaining the size of a coifee-bean in localities where the apex of 
each is free to push forward without coming into contact with adja- 
cent planes of the integument. Thus about the dorsum of the body, 
the gluteal regions, the calves of the legs, and the extensor surfaces 
of the forearms, they occur as fully developed, slightly scale-capped 
or scale- encircled, and grouped papules, often commingled with 
pustules and superficial ulcers, the polymorphic patch having a 
figure of eight or S-shaped outline. These are apt to occur in patients 
under treatment, the influence of which has interfered with the full 
evolution of the disease. 

The Small Flat Papular Syphiloderm. — The lesions 
recognized under this title differ from those just described in that they 
are not acuminate, but distinctly flattened at the apex, this flattening 
being at times so pronounced that the lesion resembles a small button or 



606 DISEASES OF THE SKIN. 

plaque. The contour is roundish or oval-shaped. They are frequently 
encountered on the face, especially near the mucous outlets, over the 
anterior and posterior surfaces of the trunk, and on the flexor aspects 
of the extremities. The palms of the hands are often affected. In color 
they exhibit the variation usual in individuals of different complexions 
and in the same individual, according to the condition of the circula- 
tion. Thus, on the face, a scarcely distinguished pink will become a 
deep, lurid, reddish-brown from an attack of sneezing, a paroxysm of 
laughter or rage, and violent exercise. The seborrhoeic condition 
noted on the face in the acuminate lesions is also occasionally seen 
about the plaques. The same is true of the scaling described above. 
The eruption is much less copious, as a rule, than with the other 
forms of syphilitic papules, due doubtless to the fact of its frequent 
occurrence in those subject to some treatment. It differs from the 
lesion about to be described with respect to its size, being rarely 
larger than the smaller buttons employed as " shirt studs ; " while the 
largest papules of the same variety may attain the size of the largest 
overcoat button. The diagnosis is in general that already given. 

The Large Flat Papulae Syphiloderm. — Here the resem- 
blance to a button is even more distinct, the lesions occurring with a 
well-delined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of the plaques is a smooth, flat plane. They commonly begin as 
macular lesions and rapidly develop at the periphery, this develop- 
ment often corresponding to centric involution, by which the shallow 
depression described above is reduced to the level of the adjacent skin 
and the lesion transformed to a ring. In shape they are circular 
and oval ; and, in size, vary from a finger-nail to the section of a 
pigeon's egg. They have the usual variation in color, and may scale 
at the edge, or over the flat top, or the depressed centre. In moist 
situations they frequently secrete a muco-purulent fluid which smears 
the papules and adjacent integument; and in the vicinity of the anus 
or genitals exhales an offensive odor. It is especially in such situa- 
tions that they occasionally degenerate by fissure or circular ulcera- 
tion. Condylomata Lata are such lesions, flat and secreting 
papules of the region named, having a whitish appearance in conse- 
quence of the mucoid secretion with which they are smeared, some- 
what transformed by the influence of heat, moisture, and either 
friction or apposition of contiguous integumentary folds. 

The eruption may become generalized, or be limited to certain sites 
of preference, as the face, neck, flexor surfaces of the extremities, and 
the ano-genital region. It is either an early, late, or intermediate 
symptom of syphilis, in my experience occurring most abundantly in 
young and delicate skins, where the disease has been ignored, and 
therefore untreated ; and most scantily in the thicker integument of 
middle life, where prompt resort has been had to appropriate medi- 
cation. 



SYPHILODERMA. 607 

Syphilitic papules undergo a series of modifications, under the 
influence of various causes, which may be enumerated as follows : 

(a) There is considerable hyperplasia of the cutaneous elements 
(papillary layer of the corium, rete, and bloodvessels), by which the 
papule becomes largely raised from the surface, so as to resemble a 
papilloma or wart, or the lesions characteristic of frambcesia. In this 
way, rarely, a portion, or the entire surface, of the body may be 
covered with light-red or violaceous red, non-ulcerative, vegetating 
growths. They secrete freely, and the discharge is liable to concrete 
into crusts, and to exhale an offensive odor. De Amicis 1 has 
described a marked instance of this lesion occurring upon the scalp, 
under the title of the " framboesioid condylomatous syphiloderm." 
A translation of his paper by myself appeared in the Archives of 
Dermatology for October, 1879, p. 39. 

(6) There is considerable hyperplasia of the elements, in conse- 
quence of which the lesion spreads laterally, while its elevation from 

Fig. 74. 




Vegetating condylomata of the vulva. (After Jullien.) 

the surface is prevented by contact with apposed surfaces. Thus is 
formed the broad, flat, moist papule, known as the vegetating mucous 
patch, condyloma, plaque muqueuse, etc. The lesions, when unal- 
tered and fully developed, are of a decidedly whitish color, from the 
puriform mucus which covers them and which, as with so many of 
the syphilodermata in moist situations, is liable to exhale an 
extremely offensive odor. When the secretion is removed the lesions 
are seen to be pinkish, or light or dark red in color, and to be either 
firm or soft, scarcely raised, and indefinite in contour, or distinctly 
elevated and very well defined. They are chiefly found in moist 
situations, where regions of the skin are apposed, as about the peri- 
neum, groins, axilla?, mammae, nates, anus, genitals, and inner faces 
of the thighs. They may coalesce so as to form palm-sized patches, 
and frequently are associated with hyperidrosis, seborrhcea oleosa, and 
the dried products of secretion from the mucous outlets adjacent. 
(c) In consequences of changes in the superficial layers of the epi- 

1 Anna]. Clin, de Osped. Incurab. 



608 



DISEASES OF THE SKIN. 



dermis, the papules may become covered with scales, either at the 
base or apex, more commonly the latter, forming thus the papulo- 
squamous syphiloderm. The scales are of a dirty grayish hue, often 
desiccated, generally attached, rarely freely exfoliating. They are 
relatively few, occurring where the lesions are closely set together. 
The desquamation may be the most suggestive feature of the patch. 
Beneath them show distinctly elevated brownish-red papules or 
merely slightly elevated, dull-red or purplish-red maculations. 
When the scales accumulate at the base of the papule, they tend to 
surround it with a circlet or collarette of exfoliated shreds of 
epidermis. 

In consequence of the thickness of the epidermis in the palms and 
soles, the papular or papulo-squamous syphiloderm of these regions 




Palmar syphiloderm. (After Keyes.) 



is presented under somewhat atypical forms. These are recognized 
as the Palmar and Plantar Syphilides. The dense stratum 
corneum of the epidermis in these situations is not readily raised from 
its underlying tissue into papular forms. Its pathological manifesta- 
tions in this disease are rather displayed in thickenings, separations, 
stainings, and frayings. 

Here, therefore, are seen dull-red maculations, covered throughout, 
or at the edge merely, by scales or epidermal shreds ; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the vessels beneath the opaque horny layer; and dis- 
tinctly elevated (not flattened) and circumscribed papules, of the usual 
livid-red color, coffee-bean to small-nut in size, often aggregated in 
patches having a tendency to assume the circinate outline. Occa- 
sionally pin-head and larger deposits resembling chalk, may be picked 
with a pointed instrument from circular beds in the palms and soles 
where the lesions first developed. These and similar spots may be 
covered with dirty-whitish, tenacious, half-loosened, epidermic flakes, 
which are quite characteristic. In yet other cases, usually in conse- 



SYPHILODERMA. 609 

quence of the motions of the hand or foot or the exigencies of toil, 
irregularly angular losses of epidermis are visible, resembling the 
fracture of a pane of glass, which project, at the edges only, over 
deep fissures, broad exulcerations, or a ham-red, tender, and newly 
formed epidermic stratum. 

The eruption is frequently seen in the centre of both palms and 
soles symmetrically, rarely upon the dorsum of the hands aud feet, 
and then never typical, but always by extension from the former 
regious ; also on the lateral surfaces of the hands, feet, fingers, and 
toes, as well as the neighboring wrists and ankles. It is a persistent, 
rebellious, and usually late cutaneous symptom of syphilis, occur- 
ring often six, eight, and more years after infection. Rarely it is 
seen within a few months after the existence of chancre, and is then 
usually manifested in its simpler forms. 

The papulo-squamous syphiloderm bears in many instances a 
strong resemblance to the patches of psoriasis, but can usually be 
readily distinguished from the latter by a consideration of the 
following points : 

The syphilide is, as a rule, not generally diffused ; displays sym- 
metry only when it involves the palms and soles ; is elevated at the 
border of the patch ; and observes the contour of the segment of a 
circle. Psoriasis is more widely diffused ; generally symmetrical ; not 
specially elevated at the border of the patches ; and the latter are 
rather more completely than partially circular in outline. In syphilis 
there is generally a history of infection, of other cutaneous or mucous 
symptoms of the disease, and in the married woman, of abortions, 
miscarriages, or birth of diseased children. All this is wanting in 
psoriasis. In the latter there is a decided predisposition to the devel- 
opment of the disease about the extensor surfaces of the joints and 
the posterior aspect of the trunk ; the syphiloderm, though it may 
occupy these situations, can rarely be found thus displayed when the 
other surfaces are neglected. The scales in psoriasis are more lustrous ; 
more freely produced and shed ; and exist significantly at an earlier 
period of the exanthem. It may be safely said that, with only such 
exceptions as prove the rule, psoriasis is never strictly limited to the 
regions of the palms and soles. A scaling, palmar or plantar disease 
of the skin in childhood is more apt to be psoriasic, though both 
diseases are seen in the early periods of puberty. 

Eczema is yet more readily recognized by its severe itching, its 
history of discharge and moisture, and its characteristic crusts. 
Ancient patches of squamous eczema are often very indeterminate in 
outline, do not ulcerate, and exhibit the scales on the surface of a 
much more deeply infiltrated area. Eczema of the palms and soles, 
when chronic, usually involves also the dorsum of the hands and feet, 
whence it has extended to the former situations. When this is not 
the case, the eczematous infiltration, if of long duration, will, in the 
vast majority of all cases, be found to involve uniformly and evenly 
the entire palm or sole, including the palmar or plantar faces of the 
digits. Eczema is, finally, much more frequently encountered either 

39 



610 DISEASES OF THE SKIN. 

solely upon the right hand in right-handed patients, or to a greater 
extent in that organ by reason of its preference in the performance of 
function. This is less common in syphilis. 



Syphiloderma Vesiculosum. 

The vesicular are either the rarest of all cutaneous symptoms of 
syphilis, or do not actually exist. Certain French authors describe 
pin-head to pea-sized, conical, globoid or umbilicated, isolated or 
grouped, aud crusting elevations of the epidermis, with lucid or 
cloudy contents, seated upon the face and genitalia. The eruption is 
described as an early syphiloderm, often exhibiting a halo of charac- 
teristic tint, the resulting crusts being granular and somewhat lighter 
in color than those which are commonly seen in the disease. Both 
small and large vesicles have been thus assigned to the disease. 

But the larger number of such lesions are, without question, either 
immature pustules, eczematous lesions in syphilitic subjects, or pure 
accidents of the syphilitic process. With regard to the first, it may 
be said that the pustular syphiloderm not rarely begins as a vesicular 
lesion ; with regard to the second, that coincidences of so common a 
disease as syphilis with other cutaneous disorders is a matter of fre- 
quent observation ; and with regard to the third, bearing in mind 
the large quantity of iodide of potassium swallowed for the relief of 
the disease, and its capability of exciting a vesicular eruption, it can 
be reasonably concluded that some, at least, of the cases of so-called 
vesicular syphilis have been imperfectly studied. 



Syphiloderma Pustulosura. 

In the light of modern knowledge of the subject of the relation 
of micro-organisms to disease, it is safe to assert of the larger num- 
ber of all pustular affections of the skin, whether in syphilitic or 
non-syphilitic subjects, that they are the results of infection with pus 
cocci. It is, therefore, not sufficient in syphilitic infection to pro- 
nounce as to the latter only. It is necessary further to explain many 
of the external phenomena of the disease by the accidents to which 
non-syphilitic patients are subject. 

This is perhaps more true of the pustular syphilodermata than of 
any other lesions exhibited in the disease. Viewed as a whole, it is 
noticeable that they occur for the most part in dispensary and hos- 
pital practice, among the impoverished, the filthy, the ill housed, and 
the poorly treated. They are decidedly rare in the clientele of the 
physician consulted chiefly by those who are cleanly, well nourished, 
and skilfully treated. If it were possible to keep the skin of the 
syphilitic subject aseptic during the management of the disease, no 
one would expect an evolution of pustular syphilodermata throughout 
its course. The lesions, therefore, described under this title may be 
regarded as for the most part due to the causes suggested above, 



SYPHILODERMA. 611 

aided by picking aud scratching the skin to an extent capable of dis- 
tributing staphylococci over the surface. In other cases, we are not 
yet in position to deny that pustules general of evolution and charac- 
teristic in appearance, may develop in consequence of luetic infection 
only, but they are rarely to be seen even of this type in the better 
class of patients. 

Pustular lesions in syphilis furthermore present a wide range of 
differences. They vary in size from a pin-head to a finger-nail ; 
may be acuminate, flat, hemispherical, or irregular in shape ; may 
be few or very numerous ; distinctly localized or generally dispersed ; 
grouped or disseminated ; and may occur from the first as minute 
vesico-pustules, or as pustular transformations of variously sized 
papules. They may be surrounded by inflammatory areolae, or 
spring from an unaltered integument, or be sub-epidermic in situation, 
and scarcely project from the surface. They may be seated upon 
superficial or deep, sharply cut, secretory ulcers, aud are usually 
covered by crusts differing in bulk and consistency, forming thus the 
pustulo-crustaceous syphilide. According to the depth of the ulcera- 
tion at the base are they followed by cicatrices. Pigmentation is a 
frequent result. The crusts which form by the desiccation of their 
contents are usually reddish-brown to greenish-black in hue, occur 
in strata or laminae by accretions from beneath, and, even when 
superimposed upon a moist and secreting ulcer, are quite adherent at 
the edges. They may occur early or late in the disease, and at either 
epoch constitute trifling or grave cutaneous lesions. They have a 
marked predisposition for involvement of the sebaceous and pilary 
follicles, and are frequently disposed about the mucous outlets of the 
body. 

Small Acuminate Pustular Syphiloderm. — This exanthem 
is usually largely diffused over an extensive surface, and probably 
represents, as Jullien has suggested, a tranfsormation from papular 
lesions due to either a pyogenic tendency of the infected subject, or 
more probably, as above suggested, to uncleanliness and external 
irritation of the skin. It is certainly rare in patients of the better 
class. The pustules are generally recognized about the pilo-sebaceous 
orifices, and upon minute papular lesions, which, as undisguised 
elements of the eruption, may be interspersed among the latter. 
They are acuminate and contain but a droplet of cloudy serum or 
pus, whose desiccation furnishes a thin yellowish or reddish-brown 
crust. The fall of the latter exposes the grayish epidermal fringe of 
the base occasionally seen in papules of similar size. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and trunk are chiefly 
involved, though the disease may be well nigh universal. Under 
the influence of treatment, minute, punctiform, and pigmented cica- 
tricial atrophic depressions form, which are not persistent. The 
eruption may be an early or late secondary symptom, but is usually 
first seen within a few months after infection. Relapses occur when 



612 DISEASES OF THE SKIN. 

treatment has been irregularly pursued. Their concomitants are 
those symptoms of syphilis proper to the period in which they 
appear. 

Large Acuminate Pustular Syphiloderm. — The lesions are 
here usually coffee-bean sized pustules, which may spring from 
macular or smaller pustular lesions, very rarely from an indurated 
or papular base. They have a thin roof-wall, occurring by prefer- 
ence where the epidermis is delicate, and are often surrounded by a 
halo. They are usually acuminate, but may, after full evolution, 
slightly flatten at the apex in consequence of partial collapse. The 
crusts are bulkier and darker in color than those of the lesions just 
described ; their bases are superficially ulcerated. They occur slowly 
or with rapidity, in disseminated or grouped forms, usually at an 
early period of the disease, though commonly after the appearance 
of some syphilide of another type. 

Small Flat Pustular Syphiloderm. — This is a relatively 
frequent manifestation of syphilis, occurring upon the face, scalp, 
trunk, and the flexor surface of the extremities. It exhibits a 
decided tendency to characteristic and circular grouping about the 
mucous outlets of the body. Such groups are composed of small, 
flat pustules, originating as reddish, macular lesious which tend to 
dry in flattish, irregular, adherent crusts. The latter either sur- 
pass the limits of the diseased surface beneath, or are conspicuous 
upon a dull brownish-red area of inflamed, and even at times 
ulcerated, aspect. Often the pustules are so closely set as to become 
confluent, and in such case a single convex crust, like a carapace, 
will often completely cover the involved area. Frequent sites of the 
exanthem are the regions about the nose and the lips, as also the 
chin, beard, and the anterior faces of the elbow and wrist-joints. 

The eruption is of the pustulo-crustaceous type, and may be 
evolved from either papular or macular lesions. In this country it 
is rarely long untreated, and when in full evolution is, therefore, not 
often presented for observation. It is usually amenable to judicious 
treatment, and, when followed by severe ulceration, destroying one 
ala of the nose or a part of the lip, the patient has usually suffered 
from either cachexia or neglect. In these same cases, less severe 
phenomena are presented in the superficial serpiginous syphilide, the 
lesions extending in circinate or annular gyrations about a sound or 
previously involved and healed centre. Thus a circlet of crusts, 
with underspreading superficial ulceration, perhaps alternating with 
pustules of various ages and reniform cicatrices, will surround the 
elbow or traverse the scalp. The resemblance to pustular eczema 
is at times suggestive ; but the ulceration and outline will aid in 
their discrimination. The lesions are usually late among the earlier 
symptoms of the disease, but may be delayed for six months after 
infection. They indicate, as a rule, either severity of the disease, or, 
much more commonly, constitutional impairment. 



PLATE VIII. 



HHHHH9 



HBBm 

J3KXIK 







* 



LARGE PUSTULO-CRUSTACEOUS SYPHILODERM OF THE 
SCALP AND BODY. 



From a cachectic patient presented at the author's clinic. 



SYPHILODERMA. 613 

Large Flat Pustular Syphiloderm. — The lesions here are, 
naturally, fully developed forms of those described above. Like the 
latter, they originate as usually numerous, maculo-papular symptoms, 
which gradually deepen into pea-sized and even larger flat pustules, 
whose further history is one of enlarging, blood-mixed, reddish- and 
greenish-brown, also flattish crusts with underspreading pus-bathed 
ulceration of varying extent. The superficial variety of this syphilo- 
derm is distinguished from the deep, chiefly by the extent of its 
ulcer, the size of its superimposed crust, and the slighter, dull-red 
areola which encircles it. 

The deep variety, like the superficial, may be limited to the scalp, 
face, neck, and flexor aspects of the extremities, or it may be much 
more widely diffused. I have seen the entire surface of the body 
covered with discrete lesions of this type in cases of unusual neglect 
or profound cachexia. It is usually of late occurrence, but in the 
so-called " galloping syphilis" of the French, it maybe precocious in 
development. The lesions are at the onset nodules or tubercles, 
which become transformed into pus, and which have a deep infil- 
trated base with a dark brown halo. Incrustation follows, with the 
formation of a conical, roundish, or oval-shaped, blackish-brown crust, 
beneath which lies a clean-cut ulcer, its sharp edges usually exactly 
roofed by the incrustation. The crust thickens by concretions from 
the foul and purulent ulcer beneath, and spreads at the periphery 
while it thickens in the centre. In this way, the stratified crust 
comes to resemble an oyster-shell, the condition described by some 
authors as Rupia, a term once employed as the name of a disease^ 
The ulcer which is exposed after removal of the crust is of charac- 
teristic syphilitic type, in its deep base, foul floor, clean-cut edges, and 
purulent secretion commingled with blood, attaining at times a diam- 
eter of several inches, and having a circular, reniform, or horseshoe- 
shaped contour. The degree of destruction it may occasion is propor- 
tioned to the constitutional vigor of the subject and the treatment 
pursued. It is usually a grave, but may be a malignant exanthem, 
though under favorable circumstances it is easily managed. It may 
be an early, though usually it is a late symptom of the disease. The 
pigmented scars left are characteristic and indelible. 

Syphiloderma Bullosum. 

Bullae in acquired syphilis are late and relatively rare lesions. 
They are pea- to large nut-sized elevations of the epidermis, filled at 
first with a cloudy serum, which is soon transformed into pus, and 
often mingled with blood. They have usually a characteristic halo 
about the periphery ; are roundish or oval in contour ; are usually 
discrete, rarely disseminated, and after development, produce char- 
acteristic crusts with underlying ulcers, identical in features with 
the rupioid sequelae of large syphilitic pustules. The eruption is 
localized by preference upon the extremities, more particularly the 
lower extremities, and is indolent in its course. It is always signifi- 



614 DISEASES OF THE SKIN. 

cant of a cachectic condition in the subject of the disease. Its more 
frequent occurrence in congenital syphilis is described later. It 
is to be distinguished from pemphigus vulgaris by its characteristic 
crusts and ulcers, considered in connection with the history and 
associated symptoms of lues. 

Syphiloderma Tuberculosum. 

In this eruption, the lesions are usually multiple, flat, roundish, 
circumscribed, firm, light to dull crimson-red nodules, beginning 
commonly as maculse of a lurid hue. They vary in size from a 
coffee-bean to small nut, and involve the entire thickness of the skin, 
often also of the subcutaneous tissue. Their surface is smooth, 
glazed, or desquamating ; and their evolution peculiar in this, that 
they rarely exhibit apical pustulation or ulcerative degeneration. 

The eruption is, with few exceptions, usually limited to one or 
more regions of the body, such as the forehead, the chin, the nucha, 
the buttocks, and the outer surface of the thighs. It is less often 
disseminated than grouped. Occasionally but a single tubercular 
lesion may be displayed upon the surface of the body, the recognition 
of whose character usually demands some skill on the part of the 
diagnostician. When occurring in groups, the typical circinate 
appearance of the syphilodermata in general may be wanting, the 
patches having an irregular boundary ; but at times the circular, 
reniform, or horseshoe-shaped outline is quite distinct, with an 
inclosed area of integument, unaltered or the seat of atrophic changes. 
At other times the lesions assume a serpiginous character and distri- 
bution, a condition to which the term 

Syphiloderma Tuberculosum Serpiginosum 

has been applied. Bumstead and Taylor, however (wisely it seems 
to me), prefer to reserve that title for the description of the serpigi- 
nous syphiloderm of ulcerative type. 

In exceptional cases the lesions thus described are marked by 
secondary changes. They may become covered on the surface with 
a thin yellowish crust ; may lose their firmness and become soft 
and rather more lurid-red in hue, from colloid, or even rarely suppu- 
rative, degeneration ; may vegetate luxuriantly and become the seat, 
especially on the scalp, of warty, growths, smeared with a semi- 
purulent secretion of disgusting odor (syphilis papillomatosa, syphilo- 
derma framboesioides) ; or may finally ulcerate, the superimposed 
crusts thickening in bulk, deepening into blackish and greenish 
shades, and covering typical syphilitic exulcerations, with character- 
istic edges, floor, base, and secretion. The degeneration in the latter 
case may be rapid, and the destruction extensive. This is, however, 
of rare occurrence. 

The course of the eruption is indolent, months usually elapsing 
before its full evolution is accomplished. In untreated cases there is 



PLATE IX. 




TUBERCULAR SYPHILODERM, RESOLUTIVE AND 
SERPIGINOUS. 

From a photograph of a hospital patient presented at the author's clinic. 



SYPHILODERMA. 615 

unquestionably produced a generalized and symmetrical sypliiloderm. 
It is rare, however, even in hospital and dispensary cases, to observe 
such generalized development ; the more superficial, generalized, and 
symmetrical the lesions, the briefer, as a rule, is the interval between 
such an eruption and the date of infection. The later the lesions, 
the more apt are they to be asymmetrical, localized, and profound in 
their involvement of the deep tissues. This sypliiloderm rarely 
appears in the second, more often in the third or fourth, still more 
rarely in the fifth, tenth, or fifteenth year of the disease. 

Resolution occurs by resorption leaving in the site of the tubercles, 
according to their age, size, and contents, livid and pigmented macu- 
lations, or peculiar, pigmented, atrophic, cicatriform areas. Scars 
following the ulcerative lesions are typical in color, shape, and career, 

Fig. 76. 




Ulcerative tubercular syphiloderm. (After Keyes.) 

the pigmentation of both cicatrix and areola blanching from centre to 
periphery, and leaving a delicate, dull -whitish, glazed, or slightly 
desquamating membranous new growth, ancient relics of this process 
resembling in appearance thin, small coin- and larger-sized, circular 
sheets of mica. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, and 
psoriasis. In lupus, the age of the subject, the character of any scars 
left upon the surface, the chronicity of the disease, and the absence 
of a history of polymorphism, will usually point to the nature of the 
disease. The tubercles of lepra are very much more indolent than 
those of syphilis, and have a characteristic oiled or varnished look, 
never the livid or dull crimson color of those last named. Set upon 
the forehead, the tubercles of syphilis, near the line of the hairs, 
never give the leonine aspect of those at the lower border of the fore- 



616 



DISEASES OF THE SKIN 



head and over the eyebrow of the leper. In epithelioma, the age of 
the subject and the history of the disease are always significant. In 
the early stage of epithelioma the patient is often in a condition of 
excellent general health, while the imprint of cachexia is distinct in 
tubercular syphilis of the skin. In the later stages of epithelioma, 
the ulcer with everted edges and eroded, hemorrhagic floor, " var- 
nished " by its translucent secretion, is totally different from the 
" punched out," syphilitic ulcer with its puriform secretion and dis- 
colored crusts. The deep infiltration of even the desquamating 
tubercular syphiloderm will distinguish it from the circular patches 
of psoriasis. 

Syphiloderma Gummatosum. 

The gumma is a lesion peculiar to syphilis ; no other disease ex- 
hibits an exactly similar feature. It is usually a late or so-called 
tertiary manifestation of the disease ; and is commonly observed in 
the form of one or relatively few, subcutaneous, strictly circumscribed, 
firm, well rounded, painless and indolent tumors or nodules which, 
when first observed, are scarcely larger than a pea. They are then 
covered by an unaltered integument and are quite movable. 

Very slowly they may, when untreated, increase in size till they 
have the dimensions of a marble, an egg, or even bodies of a consid- 
erably larger size. Sooner or later, when 
not resolved by treatment, they usually be- 
come attached ; and the overlying skin be- 
comes involved, showing by its livid, red- 
dish, or purplish hue, and its hypersemic 
areola, that it threatens to yield. Finally, 
at one or several points, the skin is so 
thinned as to be incapable of further resist- 
ance, and a thick sanious secretion is ex- 
uded, whose gummy character has given 
the lesion its name. When the inflamma- 
tion has been active, its secretion may be 
wholly or partly purulent, and in that case 
be furnished, either by the contents of the 
tumor or by the peripheral tissue which 
participates in the process. Ulcers always 
result, occasionally fistulous in type, round- 
ish or oval in contour • with edges clean 
cut, and floor purulent and extending to 
the subcutaneous tissue, tendons, aponeur- 
oses, cartilage, or bone. Thin and yield- 
ing bands or bridges of undermined skin often extend between several 
such solutions of continuity, and usually melt down in the presence 
of the destructive process. When repair is progressing, which is 
decidedly the rule as regards the ultimate result, granulations spring 
from the floor, the edges contract, and the gummatous eventually 
exhibits the appearance of a simple ulcer, save in the thinned, pur- 




Syphilitic gummata of head and 
face. (After Jullien.) 



SYPHILODERMA. 617 

plish, pigmented appearance of the outlying integument. The scars 
are typical, bleaching from the centre, and may be attached to peri- 
osteum or bone, though this is exceedingly rare. Considering the 
depth of the process, the gumma of the skin is certainly as a rule 
succeeded by less evidence of destruction than is threatened at the 
height of the process. About the neck, the cicatrices may be linear 
in shape and slightly puckered. Upon the lower extremities and 
trunk, they are usually circular or oval. 

But one gumma may appear upon the person of a single individ- 
ual and, when this is the case, it will usually be found upon the leg. 
Half a dozen or more may at other times coexist. In one instance I 
counted more than one hundred upon the person of a male patient 
who was the father of two syphilitic children, and who at the time 
had also symptoms of visceral syphilis. This number is greatly in 
excess of any previously observed by me in a single case. Gum- 
mata may develop upon any part of the body, and when situated 
over the trunk of a nerve become the seat of severe neuralgic pain. 
They are particularly amenable to treatment ; and may undergo re- 
sorption, leaving little or no trace of their former existence. 

Gummata are to be distinguished from fibrous, carcinomatous, and 
lipomatous tumors, as also from indurated and enlarged lymphatic 
ganglia. As they occur in very marked preponderance below the 
level of the knees, and are for the most part single or relatively few 
in such situation, they can by their position alone be frequently 
differentiated from each of the new growths mentioned, no one of 
which occurs by preference upon the lower extremities. As they are, 
moreover, relatively late lesions of syphilis, a history of pre-existing 
symptoms of that disease can usually be obtained. 

Erythanthema Syphiliticum. 

Under this title, Dr. E. B. Bronson, of New York, 1 describes a 
condition observed by himself in syphilitic patients. Upon a well- 
defined, crimson or livid, erythematous surface (face, palms, soles) 
appeared an abundant crop of pea- sized vesico-pustules, which were 
converted later into an exuding, whitish, elevated, and diphtheroid 
patch. The multiformity of the exanthem was characteristic. In 
parts it suggested the hydroa bulleux, of Bazin ; elsewhere, the derma- 
titis herpetiformis, of Duhring. The fluid exudation that affected the 
face was not characteristic of the evolution of the palmar and plantar 
lesions. 

Later, warty, papilliform lesions appeared over the face and neck, 
somewhat resembling secreting condylomata, and surmounting, for 
the most part, a dusky-red or erythematous surface. 

The author regarded the exanthem as primarily a syphilitic pro- 
duct, but not pathologically or etiologically a true syphiloderm. Its 
origin was possibly similar to that of the angioneurotic, trophoneur- 
otic, or reflex phenomena of skin disorders in general. 

i Medical Record, September 4, 18S6, p. 253. 



618 DISEASES OF THE SKIN. 

Syphilis of the Mucous Surfaces. 

The lesions of syphilis involving the mucous membranes, found 
chiefly in the mouth, but exhibited, also, in both acquired and infan- 
tile disease, over the nasal, aural, vaginal, anal, and balano-prepntial 
surfaces, are strictly allied to the similar symptoms in the skin. The 
differences are due to maceration of the involved surface, to the 
functions of the organs chiefly implicated, to contact, and to apposi- 
tion of contiguous parts. 

There is hence every grade of disorder from hyperemia to inflam- 
mation ; and the results of the latter in both ulceration and cicatri- 
zation, each result subject to the special modifications due to the 
syphilitic process (gummatous deposits, infiltrations, etc.). 

In the purely hypersemic forms, there is, usually at the moment 
or soon after the outbreak of general syphilis, a pharyngeal or 
pharyngo-nasal blush, spreading symmetrically or irregularly over the 
parts, accompanied often by engorgement of the tonsils, especially in 
persons previously subject to disorders of the same region due to 
other causes (catarrh, follicular tonsillitis, etc.). There is then pain 
on swallowing ; and complications may arise, producing laryngeal 
hoarseness, cough, dyspnoea, aphonia, nasal discharges, crusts block- 
ing up the passages (especially in inherited disease), and impeded 
transmission of air through the nares. Similar conditions may be 
observed about the os uteri, the peri-anal region, and other of the 
sites named above. This may be or not the precursor of the severer 
complications, mucous patches, ulcers, and other symptoms of syph- 
ilis of mucous surfaces. 

Mucous Patches (Plaques muqueuses, Schleimhautpapel, condy- 
loma, Feigwarze) are merely syphilitic papules occurring in moist 
situations, flattened by reason of apposition of affected surfaces and 
by contacts necessitated by the functions of the parts involved. 
They form upon all mucous surfaces, but are nowhere better studied 
than in the mouth, where they are most annoying and most persist- 
ent symptoms of syphilis, complicating both the early and later 
stages of the disease. 

They are roundish or oval, tumid, flattened, or very slightly de- 
pressed, pale-rosy or whitish spots moistened by mucus, either devel- 
oping as such or resulting from hypersemic plaques of the sort 
described above, or dispersed among or upon the latter. They often 
resemble the patches produced on the mucous membrane by pencilling 
the latter with a crayon of the nitrate of silver. When carefully 
inspected, many of them exhibit a loosened and partially detached 
film of membrane covering the tissue, beneath which a reddish and 
raw-looking surface appears. They are seen not merely upon strictly 
mucous surfaces, but develop on the verge of the latter (mouth, anus, 
scrotum), and even on moistened cutaneous surfaces, the edges of the 
nails in infants and persons whose hands are often macerated, be- 
tween the toes, in the vulvo-crural angles, etc. The condyloma is 



SYPHILODERMA. 619 

by many writers described separately, but the older authorities were 
by uo means in error when using, as appears above, the term condy- 
loma for both the mucous patch and the flattened creamy-looking 
secreting papules seen often about the anus and vulva of the subjects 
of syphilis, particularly those of a tender age ; for the condyloma 
is actually a flattened syphilitic papule, such as is the mucous patch, 
whose external appearances are chiefly the result of its site and sur- 
roundings. 

The secretions of these lesions are at times very offensive in odor, 
especially about the ano-genital regions, but also about the mouth 
and nose (infants, the filthy, and the neglected). They may become 
fissured (edges of the tongue, tonsils, vagina) ; may ulcerate deeply ; 
may be the seat of vegetations (papilloma, so-called esthiomene of 
the vulva, etc.) ; and, in general, furnish a highly contagious secre- 
tion. It is probable that more mucous lesions are responsible for the 
transmission of contact syphilis than are chancres. 

They are to be distinguished with care from simple aphthous 
patches in the mouth, the result of indigestion or local disturb- 
ances ; also from smokers' patches (leucoplakia buccalis, " psoriasis 
lingua?," leucoplasie). In external features, these may somewhat 
resemble each other ; but in only one, syphilis, are there other signs 
of infectious disease. The chief points of difference are : singleness, 
as a rule, of aphthous sores, and often exquisite tenderness ; multi- 
plicity, as a rule, of mucous patches, and much less soreness, though 
when ulcerated the soreness may be a conspicuous feature. Linear 
streaks and bauds, often quite insensitive, of leucoplasie patches, are 
especially found along the gums, on the lines of the inner cheek, rep- 
resenting contact with the approximated upper and lower teeth, and 
in the pocket posterior to the wisdom tooth. 

Scaly Patches, described by most authors separately, are not 
true mucous lesions of syphilis. They occur not rarely in syphilitic 
subjects, as flattish, smooth, bluish-white, or lead-white, firm, slightly 
indurated, and roundish or highly irregular plaques. They are visi- 
ble on the dorsum of the tongue, on the mucous lining of the cheeks, 
at the angles of the mouth, where they are situated often in part on 
the mucous surface and abut on the skin of the lip. The thickened 
epidermis is at times covered with adherent scales not readily re- 
moved, between which fissures form, and the patch, at first almost 
insensitive, becomes exceedingly tender and painful. 

These patches are for the most part of the order described above, 
that is, leucoplasie, due chiefly to irritation of the mucous surfaces 
by tobacco-smoke, and yet occurring in syphilitic subjects, as they are 
preceded often by typical mucous patches. They are almost exclu- 
sively seen in men. They are also rarely encountered in inherited 
syphilis. In the distinction sought to be made between the specific 
and non-specific forms, attention is called to the occurrence in the 
latter of hard, uneven, and considerably thickened patches, which 



620 DISEASES OF THE SKIN. 

occasionally proliferate, and, extending to some depth, are eventually 
transformed into epitheliomatous lesions. 

Gummatous infiltrations of mucous membranes (" sclerosis of the 
tongue/' of Fournier) occur in both circumscribed and diffuse forms, 
superficial and deep. In the diffuse superficial forms, both the 
mucous and submucous tissues are involved in a firm thickening, 
best studied on the surface of the tougue, which then becomes to the 
view polished and smooth, at times appearing as if covered with a 
thin translucent varnish. Patients themselves will often describe a 
subjective sensation of " slipperiness." These thickenings may involve 
the deeper structures by every gradation, producing eventually 
lobulated masses with intervening fissures, tender, raw, and excoriated. 
The general face of the tongue is then, as a rule, covered with a par- 
ticularly foul, dirty-grayish coat, occasionally notched at the edge 
with deep ulcers. At times it is mottled, with patches of redness 
alternating with the yellowish-white of the deposit on the surface of 
the membrane. 

The deeper gummata involve the body of the organ, and are felt as 
submucous, diffuse or circumscribed, dense thickenings, usually toler- 
ably well defined, which soften, ulcerate, and leave exposed to view 
extensive losses of substance, the floors of which are deep ulcers, indu- 
rated, sloughy, and with membranous shreds over the surface. The 
fissures of the sides of the tongue described above, may here also 
produce deeply ulcerated notches in the substance of the organ. It 
is surprising how greatly deformities of this class are relieved after 
cicatrization, even when considerable loss of tissue has resulted. 

The local treatment of all syphilitic lesions of the mucous surfaces 
is both hygienic and medicinal. All catarrhal conditions of mucous 
surfaces adjacent (vagina, nasal cavity) require attention. The sur- 
faces should be kept free from all irritation (tobacco in all forms, 
iced and hot articles of food and drink, condiments, acetous and 
alcoholic fluids in the mouth ; coitus and irritating injections of 
vulva ; napkins that have been soiled over the ano-genital region of 
infants). Locally, the nitrate of silver crayon, used as a pencil, is 
effective in the management of most patches, applied once daily, or 
every second or third day. Occasionally, stronger caustics are re- 
quired, such as the acid nitrate of mercury, or nitric acid. Mouth 
washes containing the chlorate of potash, myrrh, and honey ; fifteen 
to twenty drops of Bellamy's iodized phenol ; very dilute lotions of 
the tincture of iron, or dilute muriatic acid, a teaspoonful to a pint 
of sweetened water ; and carbolated lotions, are required in different 
cases. In very great soreness and tenderness of the mouth, only the 
blandest applications are tolerated, such as thin flaxseed tea, oat- 
meal gruel as a wash, and gum acacia water. A few formulae are 
appended : 

K . Potass, chlorat. .5 j ; 4 

Aq. dest. ad. gvj; 200 i M. 

Sig. A teaspoonful in water as a wash for the mouth and throat. 



SYPHILODERMA. 621 

&. Acid, carbolic. ^j ; 4 

Iodin. tinct | M 2 

Glycerin. J ° ' 

Spts. vin. rect. 3 ij ; 8 

Aq. dest. ad. f gj ; 32 M. 

Sig. Fifteen to twenty drops as a lotion in water for the mouth. 

R . Potass, chlorat. g j ; 41 

Aq. menth. piperit. aa ^vj ; 200j M. 

Sig. Gargle and wash for the mouth ; to be used slightly diluted. 

The internal management of these cases is that demauded by the 
general condition of the system and the stage of the disease, as 
explained in the concluding pages of this chapter. 

Syphilo derma Infantile, Acquisitum et Hsereditarium. 

Syphilis may be acquired by the infant and child at any period 
after birth, as, for example, by immediate contagion from the nipple 
of the nurse, or mediately, as by the use of utensils smeared with a 
secretion capable of transmitting the disease. Such acquired infantile 
disease displays for the most part the symptoms observed in adult 
years, except that the delicate and tender skin at this early period of 
life is apt to exhibit the moist and secreting lesions of syphilis. The 
mucous patch, the pustule, and the condyloma are here more common 
than the papulosquamous symptoms of the adult. Some influence 
is also exerted upon the disease by the dress, habits of life, and mode 
of obtaining nutriment, which are conditioned upon the helplessness 
of the young child. In this way the soiled napkin over the ano- 
genital region, the warm covering of, and free diaphoresis from, the 
general surface of the skin, and the frequent contacts of the lips with 
the nipple, suffice to determine in special regions particular local 
expressions of the constitutional vice. It is much less grave in char- 
acter and portent than the inherited form of the disease. 

Hereditary syphilis maybe first displayed in infancy or early adult 
years, and is always strictly transmitted by inheritance from one or 
both parents. The consideration of the disease being in these pages 
limited to its cutaneous manifestations, it is first to be noted that the 
infected foetus may be prematurely expelled with cutaneous symptoms 
displayed upon its surface. This generally argues in favor, either of 
intense syphilis in one or both progenitors, or, more commonly, of 
relatively recent infection of the latter. Under these circumstances 
there are usually evidences of the death of the foetus at some date 
prior to its expulsion, the skin being macerated and the epidermis 
raised from the coriuni in few or many bullous lesions, beneath which 
the derma exhibits a livid reddish or purplish hue. 

When the infant is born with a clean skin, it may be shrivelled 
and emaciated, or fat and presenting the appearance of sound health. 
Soon after, however, cutaneous manifestations appear, usually not 
before the conclusion of the first month, more commonly during the 
second, very rarely after the third and fourth. The earlier the date 
of such explosion, the more intense, as a rule, is the evidence of the 



622 DISEASES OF THE SKIN. 

disorder. The first symptoms displayed are significant of visceral 
involvement, and are, in brief, those of marasmus. Emaciation pro- 
gresses rapidly; the skin seems stretched unnaturally over the facial 
bones ; the expression is that of physical distress ; the cry becomes a 
fretful moan; the integument loses entirely the rosy hue of the 
healthy infant, and acquires instead a sallow or muddy tint; and 
very peculiar wrinkles or puckered lines radiate from the angles of 
the lips. Few observers have failed to notice the resemblance which 
then exists between the faces of these emaciated little creatures and 
those of the aged of both sexes. 

In all this, however, there is absolutely nothing characteristic of 
syphilis as distinguished from other wasting diseases of infancy. 
Chronic tubercular meningitis and the gastro-intestinal disorders of 
infancy in their extreme expression, furnish a precisely similar picture* 
This is natural enough, since all depend alike upon a similar cause, 
failure of proper performance of function on the part of the viscera 
in consequence of pathological alterations. 

The coryza of the syphilitic infant is, however, soon declared, and 
speedily gives a clew to the nature of the morbid process. The 
discharge from the nares, at first serous, later purulent, desiccates 
sufficiently to obstruct the nasal passages or, in consequence of the 
tumid condition of the membrane lining the latter, is prevented 
from escaping. Often it is furnished by mucous patches forming on 
the Schneiderian membrane. At times, crusts form so as to accumu- 
late externally about the nasal orifices, and these are seen to be 
similar to those which are apt to form also at the angles of the mouth.. 
In this way the characteristic "snuffles ' ? of the syphilitic infant are 
induced, in consequence of which it is obliged when nursing to release 
the nipple from its mouth, in order to respire, an act often accom- 
panied by a hoarse cry. The breathing of such an infant, even when 
asleep, or awake and undisturbed, is always sufficient to arouse a 
suspicion as to the nature of the disease from which it is suffering. 
The mouth, larynx, vulva, and anus are often the seat of similar 
lesions, whose development into an obstructive tumefaction secreting 
more or less profusely, or into moist condylomata, will depend largely 
upon the seat and surroundings of the lesion. 

The cutaneous symptoms of the disorder, presented usually at or 
about this time, are macular, papular, pustular, bullous, or furuncular, 
two or more of them being at times commingled, attesting thus the 
identity of the disease with the polymorphic acquired forms of 
maturer years. Maculae are early to appear upon the trunk, face, 
and extremities, usually of a livid reddish hue, commingled with 
papules, and indeed often occurring as the first manifestation of the 
latter. They are irregular as to shape, and though occasionally 
pinkish, discrete, circinate, and coffee-bean sized, often produce a 
diffuse, coppery- red, or violaceous, glazed, or moist and secreting 
surface, affecting an entire region, as the neck, the trunk, or thighs 
and genitalia. Deep excoriations and even fissures occasionally form 
in these extensive patches, and the secretions may incrust them irregu- 



SYPHILODERMA. 623 

larly, the general aspect of the patch somewhat suggesting an ecze- 
matous condition, yet remarkably differing from the latter in color. 

In hereditary as in acquired syphilis, the type of all the eruptive 
symptoms is to be sought in the papules which may spring from the 
macular described above, and develop into pustules, bulla?, or condylo- 
mata ; and, in the former case, dull red or violaceous papules of 
lenticular size, occur either in asymmetrical or symmetrical arrange- 
ment, discrete, or agglomerated in patches of infiltration. They may, 
upon the buttocks especially, scale at the apex ; or, particularly, upon 
the palms and soles, constitute by fusion a thickened desquamating 
epidermal patch; or, commouly about the ano-genital region, the 
interdigital spaces, the axillae and face, become moist, and secrete a 
puriform mucus. By vegetation or hypertrophy, they develop into 
flat or fissured condylomata, smeared with an offensive, yellowish, or 
yellowish- white discharge, and vary in size from a coin to a lesion an 
iuch or more in diameter, with corresponding variation in the degree 
of their elevation from the surface. The latter may be few or very 
numerous. Sometimes a child will appear to be well nigh covered with 
large, moist, secreting papules. The author has seen an infant with 
snuffles and maculae of the trunk, having but a single condyloma of 
the anal region. Again, the papulo-condyloma may ulcerate deeply 
and crust. It should be remembered, in studying these symptoms 
from a verbal description, that they are those of a cachectic infant 
affected with a grave disease. Death often interrupts the sequence of 
the manifestations here described. This event is usually preceded by 
the signs of apparent amelioration, shrinkage of hypertrophic growths, 
and decoloration of hyperaemic lesions and patches. Of the other 
cutaneous symptoms of hereditary syphilis, vesicles are the rarest, the 
smaller being occasionally seen, haviug a conical apex, with serous 
contents, closely set together about the lips, and springing from a 
violaceous infiltrated patch. The resulting crusts never have the 
reddish-yellow tint of those observed in eczema, nor, after rupture, 
are they followed by serous oozing from a wounded epidermis. The 
larger lesions of this sort are usually transformations of papules 
which rapidly assume a pustular phase. 

Pustular eruptions, in this form of syphilis, may be discrete or 
confluent, localized or generalized. They are particularly apt to 
occur in groups about the mucous outlets, w 7 ith maculo-papular 
lesions developed elsewhere, and may result in ulceration, often after 
development into bullae with pustular or sanious contents. The 
resulting crusts are bulky and dark colored, and, especially upon the 
face, disfiguring. The subjective sensations are probably insignifi- 
cant, since the child does not attempt to tear the surface, as in pustular 
eczema. The cachectic condition of the little patient, w T hen these 
lesions are large and numerous, is usually pronounced. They may 
be seen in typical development by the side of the nail, occasionally 
involving the matrix, and productive, in this situation, of consider- 
able swelling of the digit, with an ulcerative sequel, which com- 
monly results in distortion, and ultimate loss, of the nail- substance. 






624 DISEASES OF THE SKIN. 

Onychia, however, may result from perverted nutrition of the part, 
with increase in the friability of the nail-substance, loss of lustre, 
assumption of a dirty grayish hue, and phalangeal oedema. These 
changes are analogous to those resulting in loss of the hair where the 
follicles have been imperfectly nourished. 

The furuncles which form in other cases are either exaggerated 
manifestations of the same pyogenic tendency in the skin of the 
infant, a complication common to syphilitic and other cachectic con- 
ditions in young children, or be the result of infection with pus-cocci, 
a more frequent cause. They may be few or numerous, and are 
chiefly characterized by their indolence, the absence of laudable pus 
in their contents, the ulcerative condition left after their evacuation, 
and the bluish or purplish condition of the integument which sur- 
rounds their edges. 

Bullae in hereditary syphilis are early or late manifestations of the 
disease, and may be represented by a single lesion on the palms or 
soles (the site of their predilection), or constitute a symmetrical 
generalized efflorescence. They should be regarded as evidences of 
a grave form of the disease, being often the precursors of a fatal 
issue, as indicating a feeble resistance on the part of the epidermis to 
the fluid exudate furnished from the corium beneath. In severe 
cases the bullse are ill developed, and the integument will be seen 
to be marked here and there by small coin-sized and larger disks or 
plaques of macerated epidermis, separated from the derma by a thin 
film of serous, sanious, or purulent fluid, in quantity insufficient to 
raise the roof above the general level of the integument. When fully 
developed, they may be conical, rounded, flat, or quite flaccid, and 
surrounded by an infiltrated border of dark reddish or violaceous 
hue. Their color varies with the color of their contents. Their 
subsequent career is concluded by shallow or deep ulceration, the 
base secreting a sanious discharge. Crusts may form if the patient 
survive. A fatal termination of the disease is usually announced by 
their flattening or collapse. They may be commingled with pustules, 
maculo-papules, condylomata, and mucous patches of the anus, 
mouth, and nares, but are somewhat different from the other lesions 
described in this, that they may constitute a uniform efflorescence, no 
other cutaneous symptoms being manifested. This is explained by 
the fact to which attention has been directed, that they represent the 
state of feeblest resistance in the epidermis, the fluid exudate of ex- 
ceedingly low grade mechanically separating the rete from the tissues 
beneath. 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but as late manifestations of the disease, one or more years 
elapsing before their appearance. Their behavior is scarcely different 
from that of those observed in the acquired forms, although the 
destruction wrought by their degeneration in very late manifestations 
may be of the most intractable type. Usually there is a history of 
preceding parental or inherited disease, and coincident symptoms or 



SYPHILODERMA. 625 

sequelae of such, in the altered teeth, described by Hutchinson, of 
London, in an ancient keratitis, or in a hopeless form of surdity. 

Mucous patches are very constant symptoms of the disease, and 
represent papules of the mucous membrane, which differ from those 
seen in the skin only because they are moistened, macerated, and 
flattened by juxtaposition of neighboring tissues. They are sur- 
rounded usually by a lurid halo, and may have the pearly whiteness 
always seen when the epidermis of mucous membranes is detached 
wholly or partly from the corium ; or may lose this protecting disk 
in shreds or patches, and show, beneath, an engorged, or ulcerated 
and secreting tissue. They may be isolated or broadly confluent ; and 
oval, circular, or decidedly linear in shape ; the last named appear- 
ance being characteristic of those existing at the angles of the mouth. 

They are to be recognized as distinct from both the parasitic and 
non-parasitic forms of simple stomatitis or thrush, the former being 
due to the presence of the oidium albicans. In both of the non- 
syphilitic disorders, the mouth of the child will be seen to be very 
generally, uniformly, and symmetrically involved, the circumscribed 
patches being distinctly discrete aud resembling in color, soft whitish 
or yellowish flocculi of curdled milk. The diagnosis is always 
greatly aided by noticing the well-nigh constant occurrence of patches 
just at the angles of the syphilitic mouth, which latter has also the 
seamed and puckered appearance described above. Snuffles, syphilo- 
dermata, and marked cachexia, when established, will leave little 
doubt as to the nature of the malady. 

The future of the infant affected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired form of the disease, benignancy may be a 
conspicuous feature of the entire process. The evolution of the 
disease may be tardy; its symptoms few and unimportant; its amena- 
bility to judicious treatment speedily demonstrated. Still, the fact 
remains, that the disease when inherited is far graver than when 
acquired, the victim entering the world with its viscera and bones 
subject to profound pathological alterations. 

Etiology. — Syphilis, in the course of which appear the syphilo- 
dermata, is produced invariably either by infection, accidental or 
intentional, or by the obscure influences of heredity. The methods 
of transmission may be immediate, as in sexual congress, kissing, and 
nursing at the nipple, by which act the child may infect the nurse with 
the secretion of the mucous patches in its mouth ; or it may, instead, 
receive the disease from the excoriations on the breast of the latter. 
Or the disorder may result from the medium of utensils charged 
with an infectious secretion, such as the needles of the tattooer wet 
with saliva commingled with diseased mucus, or the lancet of the 
vaccinator covered with an intoxicated blood. Generally it may be 
said that all the discharging aud moist syphilodermata are sources of 
danger to a sound individual, both in the acquired and inherited 

40 



626 DISEASES OF THE SKIN. 

forms of the disease. By these and other similar methods, persons 
of both sexes, and of all ages, may become infected. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration of the dance will often invite to the surface a macular 
syphilide which might otherwise be less fully developed ; and fric- 
tion, as by the hat-baud over the forehead, the cuff at the wrist, and 
the shoe over the foot, demonstrates its influence by daily examples 
of determination of the morbid process to special localities. In the 
trades, the hands of the syphilitic laborer betray unmistakable evi- 
dences of the irritative effect of harsh contacts upon the skin. The 
same may be said of filth, such as the feces on the napkin of the 
infant which frequently provoke in the anal region the condylo- 
mata. It is a mistake to suppose that syphilis and syphilis only, 
is responsible for the exanthemata of that disease in all shades, 
grades, and situations. Soap and water are as efficient in preserving 
the skin of the syphilitic as of the sound ; and the infected tobacco- 
chewer pays a price for his nauseous habit. Poverty, misery, and 
wilful neglect or ignorance of the laws of hygiene, are responsible 
for a long and lengthening list of the complications of the disease. 

Pathology. — The pathological anatomy of syphilis and the syphilo- 
dermata has been carefully studied by a large number of observers, 
including Virchow, Wagner, Cornil and Ranvier, Neumann, Auspitz, 
and Biesiadecki. It must be admitted that the result, even though 
it present a fair picture of the pathological appearances exhibited by 
the several lesions subjected to examination, is yet far from furnish- 
ing an explanation of the nature and peculiarly capricious career of 
the disease. Without stopping to consider, much less discuss, the 
numerous conflicting theories respecting the nature of syphilis, 
which the investigations of the eminent authors named have not yet 
succeeded in either disproving or establishing, it can be merely 
asserted to-day that the solution of this important question has not 
yet been reached. Under the microscope, it can be clearly deter- 
mined merely, that the recognized processes of hyperemia, exudation, 
hypertrophy, new growth, and degeneration (caseous, fatty, amyloid, 
atrophic, and necrotic) occur in syphilis as in some other disorders 
with cutaneous lesions ; that the specific character of the disease is 
not betrayed by any specificity of elements or of their arrangement ; 
and yet that every pathological process of syphilis bears the imprint 
of the malady whose influence it acknowledges. Here is a lesson 
certainly confirmed by clinical facts. With the possible exception of 
the gumma, there are no Gutaneous lesions of syphilis which are 
peculiar to itself, and yet there are certain modes of behavior by 
which each, when carefully studied, betrays its identity. It is then 
by the modality rather than by any essential character of the syphi- 
litic process, that it is to be differentiated from all others. 

The papule, the tubercle, and the gumma may be regarded as 
typical pathological developments of the disease, as they certainly 



SYPHILODERMA. 627 

constitute the basis of its common and important cutaneous manifes- 
tations. One of them indeed, the gumma, may develop in any organ 
of the body other than the skin. Under the microscope, these lesions 
are seen to be made up of a new growth whose numerous, small, 
rounded, or spindle-shaped elements, whether derived from connective 
tissue or outwandered leucocytes or both, and whether found, as they 
may be, in the rete, the corium, or the subcutaneous tissue, very 
probably represent transformation of protoplasm previously existing, 
or resulting from embryonal metamorphosis of such pre-existing 
elements. Kaposi well summarizes the chief peculiarities of this 
new growth, by remarking : First, that its elements are distinctly 
circumscribed and homogeneous, differing, the minutest papule from 
the largest tubercle, only in respect to volume ; second, that they are 
inapt for permanent organization, but retrograde and disappear either 
by resorption or by suppuration ; third, that they are remarkable for 
their tendency to coincident evolution and involution, usually in a 
centrifugal direction, the younger peripheral portions presenting the 
characters of recent infiltration, while the more ancient situated at 
the pathological centre, are earliest to disappear. 

This new growth naturally plays a more important part in some 
lesious than in others. Scarcely discernible in the hyperemia of the 
macular lesions and well defined in the papule and its modifications 
(the tubercle, the condyloma, and the forming gumma), it is repre- 
sented in the vesicle, pustule, bulla, and degenerating gumma by 
either a fluid exudate composed of granular, cloudy, and nucleated 
elements, or by a soft, succulent, grayish, or grayish-red homogeneous 
mass, yielding a scanty juice, and not yet completely transformed by 
degeneration to the fluid condition. Beneath and about any of these 
last-named lesions, the circumscribed new growth may lay a founda- 
tion or erect a wall which unmistakably asserts the unity of all such 
processes. 

Viewed comprehensively, the multiform developments of the 
syphilitic new growth are seen to be incontestably more rapid of 
evolution and involution than, in their average career, are all the 
neoplasmata. Sarcoma alone competes with it in this regard. Lepra, 
lupus erythematosus, lupus vulgaris, keloid, xanthoma, and the large 
majority of all forms of epithelioma outlive, as a rule, generations of 
syphilodermata. This relative rapidity of career has entailed upon 
the disease its possibilities in the direction both of benignancy and 
malignancy. Whether, as it may, it destroy life, or, as may also be 
the case, it so slightly interfere with health as well nigh to pass un- 
noticed, in either event the total period of its activity is relatively brief. 

The demonstration of the bacillary origin of syphilis, as already 
stated, is not yet complete. Every fact in its history, however, and 
the recent advances in the discovery of the part played by micro- 
organisms in the production of other diseases, point unmistakably to 
a parasitic origin of syphilis. There is reasonable ground for believ- 
ing to-day that the disease belongs to the class of infectious granulo- 
mata, even if the conclusions of Lustgarten and Doutrelepont be not 



628 DISEASES OF THE SKIN. 

confirmed by further experiment, the crucial test being a series of 
productions of syphilis in unmistakably sound individuals, by infec- 
tion with a product of bacilli obtained by cultivation. 

Lustgarten first hardened sections of syphilitic lesions (initial 
chancres, papules, and gummata) in absolute alcohol and colored 
them in a solution of gentian-violet for twelve to twenty-four hours 
at the ordinary temperature and then for two hours at 104° F. The 
sections were decolorized by repeated washings in absolute alcohol, a 
one and one-half per cent, aqueous solution of the permanganate of 
potassium, and chemically pure sulphurous acid. 

It is claimed that by the special method employed, character- 
istic organisms were always recognized in syphilitic and never in 
non-syphilitic lesions. The bacilli were never free but always 
enclosed in cells of amoeboid movement, resembling lymphoid cells. 
These bodies were straight, curved, or irregularly bent in rod-like 
forms, averaging three and one-half to four and three-tenths of a 
micromillimetre in thickness. Under objectives of low power they 
presented a uniform smoothness with occasional terminal bulbous 
expansions. The surface, however, viewed under a homogeneous 
immersion lens, appeared irregularly undulating and slightly notched, 
the bacillus or rod-like appearance, however, remaining distinct. 
Within each bacillus, separated from each other by spaces of equal 
length, were from two to four bright and colorless spores. 

More recently, however, micro organisms, similar to those believed 
to be the sources of syphilis, have been discovered in the smegma 
preputii and other secretions obtained from the genital organs of 
non-infected persons of both sexes, thus confirming the belief that the 
specific bacterium of the disease has not been recognized. 

Diagnosis. — The syphilodermata are to be distinguished from all 
other cutaneous eruptions by their general characteristics and by the 
features peculiar to each lesion. It must not be forgotten, however, 
that these lesions are not essentially different in character from all 
others, but are to be recognized with ease or difficulty, according as 
they do or do not betray the syphilitic expression. No one, however 
expert in diagnosis, can always trust himself to recognize these special 
features by a study of the eruption only, at a given moment of time. 
Neither in respect to color, form, size, situation, disposition, or other 
peculiarity, do the syphilodermata exhibit an absolute difference 
from the non-syphilitic affections of the skin. It is therefore requi- 
site in every case to investigate in the fullest manner, the history of 
the disease, of all prior skin lesions, of a primary sclerosis (when 
this can be obtained), of adenopathy, miscarriages, abortions, and 
disorders affecting other organs of the body, such as the bones, 
viscera, organs of sense, and the mucous surfaces. Often a single 
extra-cutaneous fact will be a valuable aid in establishing the 
diagnosis of syphilis. An " eczematous " infant, with snuffles and 
a hoarse cry, has been treated in vain by many a physician, other- 
wise capable of making a diagnosis, who might have been given a 
clew to the nature of the disease from which the child was suffering, 



SYPHILODERMA. 629 

if he bad taken the pains to inspect the amis and question the father 
in private. 

It is very necessary in this connection to lay stress upon the well- 
known fact that every syphilitic patient with a disease of the skin 
does not necessarily exhibit syphilodermata. The course of the dis- 
ease is in many cases so protracted that patients have ample oppor- 
tunities to contract other disorders, and their number is larger than 
is commonly supposed to be the case. They suffer most often from 
the medicamentous eruptions, especially those induced by the inges- 
tion of iodide of potassium (q. v.) ; are, like other men and women, 
bitten by bugs and lice ; and suffer from eczema, acne, psoriasis, and 
other non-venereal disorders. This is less true possibly of the inno- 
cent victims of the disease than of those guilty of sexual excesses in 
and out of the married state, many of the latter leading the most 
disordered lives, and exposing themselves to the ordinary causes of 
disease to a degree not noted in other persons. 

It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis, and, if that fact cannot be indubitably determined, to be 
careful that the statements of the patient be not allowed to bias the 
judgment in pronouncing upon any eruption present ; second, sup- 
posing that such a fact is established by clinical proofs without 
reserve, to determine whether the eruption present is produced by 
the existing syphilis or some other externally or internally operating 
cause; aud if this last be determined, to be careful in eliminating the 
syphilitic influence from its operation. 

Ignored syphilis is usually severe ; but it is without avail that 
disorders of a different character are treated by the methods useful 
in the former. Thousands are annually so mistreated who might be 
spared such a course. The frequent occurrence, after a suspicious 
exposure, of a balanitis, an attack of progenital herpes, uninfected 
excoriations, blennorrhagic discharges, and even the appearance of 
molluscous tumors, warts, and parasitic cutaneous disorders upon the 
genital region, is a source of alarm and of fruitful error to the many 
rather than to the few. 

On the other hand, the diagnostician must be ever on the alert to 
recognize the symptoms of the disease in those who least suspect it. 
Thus, married women complaining of a " humor of the blood," men 
who have been " overheated, and broken out with a rash," and a 
long list of patients exhibiting upon their persons the symptoms of 
" salt rheum," " tetter," "scrofulous ulcers," and " erysipelas " are 
those whose speedy relief will depend upon the skill of the prac- 
titioner in recognizing exactly the precise nature of the malady. 

The diagnosis of the syphilitic lesions of the skin is a matter of 
the very greatest importance, inasmuch as the health, comfort, mental 
happiness, and domestic relations of thousands of men and women 
annually depend upon it alone. An error in either direction may 
involve the most serious consequences to both physician and patient. 
He is but poorly qualified to discharge the important duties of a 



630 DISEASES OF THE SKIN. 

general practitioner of medicine who has not carefully trained him- 
self to establish the truth in these cases, irrespective of the diagnosis 
of the patient, and of all others who may have been consulted. 

Treatment. — The syphilodermata are to be treated by topical appli- 
cations intended to hasten their disappearance or involution, but as 
local manifestations of a constitutional disease, their management is 
largely that which looks to the relief of the latter. 

The treatment of syphilis will, in the pages which follow, be 
described in outline, so far as it relates to the relief of the cutaneous 
lesions and of the systemic condition. The important modifications 
of therapy which are required in the management of syphilis of the 
osseous and nervous system, of the respiratory, gastro- intestinal, and 
other organs, it is scarcely necessary to remark, are fully described 
in the standard treatises specially devoted to this subject. Among 
them may be named, as of American authorship, the sterling works 
of Bumstead and Taylor f of Van Buren and Keyes ; 2 of Morrow, 3 
and of E. L. Keyes.* Of those more or less recently published abroad 
may be named the standard treatises of Lancereaux; 5 of Jullien; 6 
of Fournier; 7 of Diday and Doyon; 8 of Zeissl ; 9 and of Mauriac. 10 

The first and often the most important consideration for the prac- 
titioner who is in face of a syphilitic patient is the care of that 
patient's general health. Simple and natural as it may be to set 
down such an injunction in this connection, its importance rests upon 
the fact that it is too often neglected. Patient and physician are 
often respectively hurried into the precipitate ordering and swallow- 
ing of specific drugs, without regard to other as important details. 

The author is in the habit of handing to the patient, at the outset 
of all treatment for syphilis, a slip of paper on which are printed in 
concise and simple terms a set of rules which should be observed 
during its continuance. For physicians who do not take similar pre- 
cautions, it is advisable to enter rather fully into the explanation of 
certain details which the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the 
nature of the disease recognized, since every infected patient has an 
interest in knowing such fact, and it has an important bearing upon 
his or her relations to the uninfected. To every such person, with 
the assurance that the disease is often benign, and productive of 
little discomfort, and in any case curable, it should be stated that the 
affection is contagious, and capable of transmission to sound persons 
by physical contacts of various characters. The patient should be 
instructed as to the nutritious character of the diet he should select, 
and should be informed that an increase in weight, while subjected 

1 The Pathology and Treatment of Venereal Diseases, Philadelphia, 1883. 

2 A Practical Treatise on the Surgical Diseases of the Genito-urinary Organs, including 
Syphilis, New York, 1874. 

3 Syst. of Gen.-urin. Dis., Syph., and Derm., New York, 1893 (3 vols.). 

4 Surgical Diseases ol the Genito-urinary Organs, including Syphilis, New York, 1888. 

5 Traite historique et pratique sur la Syphilis, Paris, 1874. 

6 Traite pratique des Maladies Veneriennes, Paris. 1886. 

" Leyons sur la Syphilis, etc., Paris, 1873. La Syph. Hered. tard.. 1886. 
s Therapeutique des Maladies Veneriennes, Paris, 1876. 
9 Lehrbuch der Syphilis, etc., Stuttgart, 1875. 
10 Le?ons sur les Malad. Vener., Paris, 1883. 



SYPHILODERMA. 631 

to treatment, is decidedly favorable in the matter of prognosis ; that 
the starving and sweating processes so highly esteemed by the char- 
latan and the advocate of the virtues of the waters of certain resorts 
are relics of antiquity, as useless in fact as they are frequent sources 
of peril. 

The bathing of the body is a matter of importance. Hot, Turkish, 
and Russian baths are, as a rule, to be interdicted, inasmuch as they 
tend to invite cutaneous hyperemia, and thus to favor the occurrence 
of eruptions. Cool or tepid baths are to be employed sufficiently 
often for the purposes of cleanliness, and by the sponge rather than 
by immersion. Dry friction of the surface of the body daily may 
be ordered with advantage where the skin is still sound. The teeth, 
mouth, and gums require constant care. The use of the tooth-brush 
with cool water twice daily is a matter of importance, to be preceded 
for a time, when the gums at the outset are in a tender, fungous, or 
hemorrhagic state, by gentle friction with the finger, covered by a 
handkerchief dipped in a weak spirit-and- water lotion, to which the 
tincture of cinchona and of myrrh may be added in any desired pro- 
portion. Tobacco in every form is, without any question, decidedly 
injurious. Often the patient should be sent early to a competent 
dentist for the extraction or filling of carious teeth, and the removal 
by the file or dental engine of all sharp projecting edges. 

Malt liquors, wines, and spirits should be employed solely under 
the explicit direction of the physician. They are exceedingly useful 
in debilitated subjects of a certain class, and need not be prohibited 
in toto to those long habituated to their use. At the same time, an 
improper use of such stimulants is, it need not be said, in the highest 
degree harmful. When employed at all, they should be rigidly re- 
stricted to the dining- table and the hours of meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the non-infected. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has 
proved exhausting, the recreation of travel — the claims of all these 
need at times to be urged by the physician. With this the patient 
should be encouraged to free his or her mind from needless anxiety, 
and to avoid particularly the company and conversation of those 
similarly infected, whose opinions are based too often upon ignorance, 
or a knowledge of half truths. The literature of syphilis is, for a 
similar reason, to be eschewed, as the mass of patients, too many of 
whom purchase treatises on the subject, are able only to glean imper- 
fectly the meaning of the authors consulted. 

It should be a rule to urge married patients frankly to inform the 
partner of the fact of infection, for the sake of both. When this 
advice is followed, much trouble is avoided for the future, and one 
of the obstacles to a completely favorable issue is at once set aside. 
In the author's professional experience, many instances have occurred 
in which the disruption of the conjugal bond resulted from infection 
of one, but usually of both parties ; but it is a striking argument in 
favor of the policy here urged, that in this entire experience there 



632 DISEASES OF THE SKIN. 

has been no single instance in which a frank and honorable confes- 
sion has been followed by such a consequence. It should be added 
that in no one of the " confessed" cases has there been subsequent 
infection of the innocent. It need scarcely be said that the larger 
number of these patients have been husbands. Recently infected 
young adults w^ho have contracted a marriage engagement should 
invariably claim release from such a tie for the sake of all con- 
cerned. The syphilitic nurse must be taken at once from the sound 
nursling, and the child with hereditary syphilis be suckled only by 
its own mother. The latter, according to the law of Colles, the 
exceptions to which are so few as to prove the rule, always enjoys 
immunity against the diseased mouth of her own child. 

Turning to the consideration of the medicaments employed in 
syphilis, it is to be remarked at the outset that there is no routine 
plan of treatment which in every case can be advantageously em- 
ployed. In no respect do physicians so differ from each other, 
judged by the standard of professional skill, as in their ability to use 
a single remedy with success. He who has the largest armament- 
arium is not always either the best equipped or the most successful. 
Mercury, iodine, iron, and quinine are the great remedial agents in 
syphilis, but they may also be used vainly by one man in the long 
effort to accomplish that which another achieves speedily and bril- 
liantly by use of the same remedies, employed with greater skill. 

Of the other substances vaunted as either advantageous or specific 
in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guaiacum, tayuya, mezereon, and the long list of other vegetable pre- 
parations whose virtues have thus been extolled, are all as harmless 
in themselves as they are ineffectual for the relief of the malady. 

Before proceeding, however, to assume the responsibility of 
directing a course of treatment for syphilis with remedies of acknowl- 
edged value, the physician will do well to remember that no two 
cases of the disease are precisely similar, and that there is the widest 
range between the most benignant forms encountered in private 
practice and the malignant cases that are seen in hospital wards. 
Some forms of the malady are so absolutely mild as to constitute an 
inconvenience merely ; others, so severe as to destroy life. It is an 
axiom in venereal disease, that more patients perish annually from 
blennorrhagia and its results than from syphilis. There could be 
no greater error than to treat any disease exhibiting so wide a vari- 
ation in severity, by a uniform method. 

Mercury, after the assaults upon it of generations of men of 
admitted wisdom and candor, stands to-day unrivalled as a remedy 
for the relief particularly of those stages of syphilis in which the skin 
is involved. Administered with skill, it can be given for years at a 
time with immense advantage to the syphilitic, who, during a well- 
regulated mercurial course, should gain in weight, improve in vigor, 
and exhibit a healthy color of the skin. No competent physician 
of to-day employs it in such a manner as to induce salivation or any 



SYPHILODERMA. 633 

other of its toxic effects. During the last twenty years the author 
has had the opportunity not merely of making large use of this drug 
in his own practice, but of seeing many patients treated by other 
physicians in a similar way. In about a dozen cases there were 
excessive toxic effects of the remedy, and in each the carelessness or 
ignorance of the prescriber was responsible for the result. It should 
be remembered that in every discussion of the merits of mercury in 
syphilis, both physicians and patients have been guilty of the ignor- 
ance or folly of ascribing to the remedy the disastrous effects of the 
disease. 

Mercury may be given by the mouth, by inunction, by subcu- 
taneous injection, or externally by the aid of the vapor bath. Decid- 
edly the most popular method, and that productive of least inconve- 
nience to all concerned, is the method by ingestion. 

In the treatment of syphilis, the mild chloride, corrosive sublimate, 
and bicyanide of mercury, together with blue mass, may be effectively 
employed. These preparations are, however, rather less adapted 
than others for continued employment during long periods of time, 
and are open to the objection of either readily undergoing re- 
arrangement into more stable compounds of the metal, or of pro- 
ducing undesirable irritative effects. With the protiodide and bin- 
iodide of mercury an impression can be produced upon the system 
which can be readily proportioned to the exigencies arising in every 
case, which can be sustained during that " chronic medication " which 
Fournier declares to be requisite in every chronic disease, and which 
can be exerted without fear of immediate or remote deleterious con- 
sequences. 

Treatment of syphilis by the mercurial selected for use should, as 
a rule, be begun only at the moment of evolution of constitutional 
symptoms The initial sclerosis of the disease is, to a remarkable 
extent, amenable to the action of the metal, but in the large propor- 
tion of cases will cicatrize, when in an ulcerative stage, without 
having recourse to general medication. The latter may be well 
reserved, as suggested by Bumstead and Taylor, for such primary 
lesions as are threatening in symptoms, and for such individuals as 
require or demand speedy cicatrization of their chancres, as, for ex- 
ample, those about to travel beyond the reach of medical assistance. 
Personal experience fully confirms the wisdom of the teaching which 
reserves specific medication till the second period of incubation has 
passed. No local or general treatment can avert either a mild or 
severe explosion of symptoms after that period is completed. In the 
experiments made by the author, in order to determine this point, 
there was either the production of strikingly irritative effects, such as 
very marked relapse, or unusual increase in the volume of the initial 
sclerosis immediately before the evolution of the first syphilodermata, 
or a distinct obstinacy in the latter to the action of the medicament 
employed. 

In the early stages of syphilis in adults, the protiodide of mercury 
may be named as one of the most trustworthy of preparations. Of 



634 DISEASES OF THE SKIN". 

all classes of adult patients, including strong males and delicate 
females, there are scarcely two per cent, who cannot take it, if the dose 
be proportioned to the individual susceptibility. It is usually ad- 
ministered in pill or tablet form, in doses of one-fifth (0.01), one- 
fourth (0.016), or one-third (0.022) of a grain, three times daily, 
combined with the extract of gentiau. The dose may be gradually 
increased, according to the necessities of the case, from one-half 
(0.032) to three (0.266), and even four (0.332) grains in the twenty- 
four hours. Many of the gelatin-coated pills found in the market 
contain accurately divided doses of the salt. The sugar-coated pills 
of Messrs. Gamier and Lamoureux, containing each one centigramme 
of the protiodide, are efficient and largely employed. 

Commencing with a minimum dose, the remedy is to be steadily 
exhibited, and the daily quantity consumed very gradually increased, 
till the degree of tolerance of which the patient is capable has been 
ascertained. Should the stools become frequent, pain be excited, or 
a slight effect be produced upon the mouth, such as is indicated by a 
metallic taste, moderate increase in the quantity of saliva, or any 
noticeable degree of tenderness of the gums, the dosage is to be grad- 
ually diminished till these symptoms disappear. Often the with 
drawal of a fifth (0.01) or a half (0.032) of a grain daily, will suffice 
to enable the patient to tolerate the quantity thus diminished. The 
medication is to be faithfully continued till the object in view is 
obtained, viz., relief of all symptoms of the disease. 

Keyes's well-known, so-called " tonic treatment of syphilis " is 
based largely upon the plan whose outline is merely sketched above. 
By the method which this author has certainly popularized, the 
dosage is increased only on each third or fourth day, till irritative 
effects are produced, when, after an interval of two days, the quantity 
taken at the time of the production of such effects is reduced one-half 
to one-third. This reduced quantity is termed the " tonic dose," and 
is thereafter continued throughout the treatment in " nearly all con- 
ditions of health or disease." 1 

This method of treatment is in many cases admirably effective and 
is eminently safe. Still, viewing the subject with the conservatism 
which its importance justifies and which a mass of clinical facts 
demands, it may be well doubted whether it is always proper to 
administer a mercurial for weeks at a time to a man in apparently 
good health. With the active measures at immediate control in the 
mercurial vapor bath, it is usually safe and not unwise to suspend 
temporarily specific medication of the patient who exhibits such 
amelioration of symptoms as to be free from external manifestations 
of the disease. Every syphilis has its periods of activity and repose. 
Such an hour of repose will be well employed in the administration 
of iron, which, as tending to relieve the distinct chloro-anaemia of 
the disease, has its claims to recognition in the list of " specific " 

1 Consult the interesting paper of the author in the American Journal of the Med. Sci., 
January, 1876 ; also his later exposition of his views in the Philada. Med. Times, November 
25, 1882, p. 337. 



SYPH1L0DERMA. 635 

remedies. No case of syphilis can be said to have been properly 
treated, in which this remedy has not been given for at least a part 
of the time during which the patient was under observation. The 
citrate of iron and quinia is an excellent preparation for this 
purpose, administered at the meal hours, in a small quantity of 
sound sherry wine ; or the iodide of iron may be employed in syrup, 
or in the pills made by the formula of Blaucard, or in Vallet's mass. 
In other cases, the muriated tincture may be employed, but the phy- 
sician will always be careful about ordering an acid preparation of 
any kind during the intervals of a mercurial course. There is no 
form of anaemia which responds more promptly to the chalybeates 
than does that produced by the syphilitic virus. 

The biniodide may be substituted for the protiodide when, for any 
reason, it may be thought desirable, commencing with a minimum 
dose of one sixty-fourth of a grain (0.001), and increasing this 
gradually to one-fortieth (0.0016) or rarely to one-twentieth (0.0033), 
either in pill or solution. The average dose of one-fortieth (0.0016) 
of a grain in pill form, administered three times daily, soon after 
eating, is tolerated by the majority of all patients of both sexes with- 
out consciousness of unpleasant effects. 

For those who prefer to use the rather more active and correspond- 
ingly dangerous salts of the metal, calomel may be administered in 
one or two grain doses (0. 066-0.133) three times daily, in combina- 
tion with an opiate to prevent its action on the bowels, or, as recom- 
mended by Peters, in one-tenth (0.0066) of a grain dose every hour. 
Small doses of blue mass or gray powder may also be employed. 
According to the traditions of the profession, the gray powder is 
most suitable for children and infants, but since the frequent dis- 
covery in the latter of the corrosive chloride, either as of early or 
late chemical production, it is less esteemed. The homoeopathic first 
decimal trituration of calomel with sugar of milk is a far more 
suitable compound. Corrosive sublimate in doses of from one- 
twentieth (0.0033) to one-twelfth (0.005) of a grain is exhibited in 
pill form or in solution ; and is probably more generally employed in 
the treatment of syphilis than any other mercurial salt. The objec- 
tions to its use are suggested above. Though constantly employed 
in the public charities, where it is furnished as a cheap and a con- 
venient substitute for the more elegant preparations in the market, 
it is much less frequently ordered for syphilitic patients in private 
practice. When given in solution, it produces a disagreeable metallic 
taste in the mouth, which some patients can perceive after the lapse 
of six hours. 

With many physicians of wide experience, it is customary to employ 
opium, either alone or in connection with the use of mercury, for the 
relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent the 
cathartic action of the metal upon the bowels, and again because it is 
supposed to possess some power of arrest over the destructive action 
of the disease. It should not, as a rule, be exhibited when by 



636 DISEASES OF THE SKIN. 

reducing the mercurial or exchanging the latter for a ferruginous dose, 
the same result can be reached. Few syphilitic patients are in the end 
brought to the desired termination of the disorder by the use of a 
remedy which interferes with assimilation and digestion ; and such a 
remedy is opium in all its forms. Temporary advantage is often 
gained by its employment, but this may be more than counteracted 
by its ultimate effect upon the gastro-intestinal tract. 

Mercury is also satisfactorily introduced by the method of inunc- 
tion. The metal, when thus employed, is readily absorbed by the 
system, and its therapeutic value is no less evident. Inunction 
should be employed in every case which admits of it, since the gastro- 
intestinal tract is thus left undisturbed, and, further, the dose of any 
needed chalybeate or the iodide of potassium per os, can be regulated 
without increasing or diminishing the quantity of mercury in daily 
use. Mercurial ointment is commonly used for this purpose, but a 
much more cleanly substitute for it is provided in the oleate of 
mercury in the strength of ten, fifteen, or twenty per cent. There 
is but little question that the oleate also is somewhat more readily 
absorbed from the surface of the skin. The ten per cent, oleate is 
in general to be preferred to the stronger preparation, as less liable 
to irritate the surface of the skin. From half a drachm to a drachm 
(2.-4.) of either the ointment or the oleate can be rubbed into the 
skin at night before retiring, and the part selected for inunction 
cleansed by washing in the morning. Both, if continuously applied 
to a single portion of the skin, are liable to produce a mild local 
dermatitis or eczema, and hence it is wise to select on successive 
evenings a fresh portion of integument for the local application, 
preferably that where the epidermis is relatively thin, as, for example, 
the flexor aspects of the joints. The patient can thus upon one 
evening anoint the internal faces of the thighs ; upon the next, the 
sides of the chest ; upon another, the loins, etc., taking care to 
avoid surfaces where an induced eczema is likely to prove especially 
annoying, such as the scrotum, the axillae, and the groins. The 
oleate may in some cases be well rubbed into the soles of the feet 
previously soaked in warm water, after which the socks or stockings 
may be drawn over the feet for the night. In the case of infants, the 
inunction is well performed by the natural movements of the child, 
if a flannel swathing-band previously smeared with the oleate be 
wrapped about its belly, so that the mercurial comes in contact with 
the skin. Should local irritative effects be produced, these subside 
rapidly, as a rule, after a warm alkaline ablution followed with a 
bland dusting powder. Subsequently or even before such accident 
in the case of infants or patients having unusually sensitive skins, the 
oleate may be mixed with equal parts of vaseline, lard, or olive oil. 
As some patients become disgusted with this routine, it is well at the 
onset to flavor the substance selected for inunction with lavender, 
rosemary, or bergamot. 

In this country too little attention has been attracted to the treat- 
ment of syphilis by mercurial inunction. With this in view the pre- 



SYPHILODERMA. 637 

ceding paragraphs which describe the use of mercury by the mouth 
are to be understood as related in all cases to the employment of the 
metal by the skin. It is well to order inunction in all practicable 
cases ; to save the stomach as much as possible ; to continue with the 
oleate nightly, weekly, or less frequently so long as there is danger 
of relapse; and to adjust carefully the quantity employed to the 
exigencies of the case. In this manner patients may be relieved 
of all symptoms of the disease who have not during their treatment 
swallowed a dose of mercury, and the permanency of whose relief 
may be tested during years of subsequent observation. 

One of the most effective methods of administering the metal is 
by fumigation in the mercurial vapor bath. It is employed by 
many experts as the sole means of exhibiting the mercurial selected 
for use, but is, for the average of patients, too inconvenient for con- 
tinuous employment. It should be regularly ordered first, in all 
cases where the earliest syphilodermata are intense, generalized, and 
particularly conspicuous upon the face; second, in all obstinate cases 
where the patients are not women nor cachectic subjects of either sex ; 
third, at the outset of treatment of many " ignored " cases, where the 
syphilodermata, either more or less generalized, have proceeded to 
uninterrupted evolution ; fourth, in the severe cases of patients coming 
from the country to the city, and able to remain but a brief time 
within reach of the advantages offered in the metropolitan centres. 
From half a drachm to a drachm (2.-4.) of calomel, metallic mercury, 
the bisulphuret, the black oxide, or the hydrargyrum cum creta may 
be employed for each bath. It is common to order from a scruple 
to a drachm each (1.-4.) of calomel and cinnabar. The patient is 
stripped of his clothing and seated in a chair, the patient and chair 
being completely enveloped in blankets, which are closely fastened 
at the neck of the bather. Beneath the chair is an alcohol lamp, sur- 
mounted by a tin vessel containing water in ebullition, the hot vapor 
of which in a few moments induces copious perspiration. When this 
result is obtained, the lamp is brought beneath a metal plate contain- 
ing the substance to be volatilized. The patient remains exposed to the 
vapor about ten minutes after this process of sublimation is finished, 
and retires at once to bed without cleansing the skin, the fumigation 
being preferably conducted before the hours of sleep. In the morning 
a bath may be taken for the purpose of cleanliness. It is more con- 
venient in the generation of the vapor in this way, to make use of 
Mr. Henry Lee's safety fumigating lamp, but the materials requisite 
for the production of all desired effects, with the exception of the 
alcohol lamp, can be procured of any good tinsmith. In the city, 
male patients are often sent to the bath-houses, where the fumiga- 
tion is conducted in the daytime ; and rarely experience as a con- 
sequence unpleasant effects, such as are popularly associated with 
" taking cold " after exposure to the action of mercury. In the most 
of these establishments provision is made so that the head also can 
be exposed to the mercurial fumes, respiration being conducted 
through a tube in connection with pure air, a provision useful in cer- 



638 



DISEASES OF THE SKIN 



tain cases of emergency ; and only " emergency cases " should be 
required to resort to such measures. 

The happy effect of the mercurial vapor bath is often marvellously 
rapid. A generalized syphiloderm may become well-nigh indistin- 
guishable upon the surface after four baths at intervals of two days 
each. With this potent agency at hand, it can be well understood 
how the skilled physician can afford to watch his syphilitic patient 
from week to week, taking a dose of iron internally and employing 
inunction externally, the few lesions fading slowly from the surface, 
all fears quieted, and the nutrition sustained at a high grade. In 
comparison with this combined method, the swallowing of blue mass, 
or calomel and opium, should be regarded as a more clumsy and 
dangerous procedure. 



Fig. 7 




Lee's lamp for fumigation. 

The injection of mercury in the deep muscular tissue (the gluteus 
in its thickest part with the muscle wholly relaxed ; the trapezius 
above the upper scapular angle with equal lack of tension) as well as 
when practised more strictly hypodermatically, requires all antiseptic 
precautions both as to the point where the needle is inserted and as to 
the instrument itself. It is to be remembered that these injections 
have occasionally proved fatal (calomel, gray oil), and grave mischief 
has followed in one or two instances from visceral troubles. 

This method was first popularized by Lewin, 1 and is open to the 



1 Die Behandlung der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; also trans- 
lated by Proegler and Gale, Phila., 1872. 



SYPHILODEKMA. 639 

serious objection of requiring the aid of the physician for the admin- 
istration of each dose. It is efficient and speedy, but will probably 
always find largest favor in the treatment of patients in hospital, 
who are there completely subject to the orders of their medical attend- 
ant. At the site of the injections, too, not rarely abscesses have 
formed. One-twelfth (0.005) or one-eighth of a grain (0.008) of 
corrosive sublimate, dissolved in ten or fifteen minims of distilled 
water, may be injected at a time, the operation being repeated upon 
about twenty occasions. Bamberger, of Vienna, has reported favor- 
able results after the injection of an albuminate or a peptone of mer- 
cury, thus attempting to avoid the danger of localized abscesses, and 
insuring speedy absorption of the metal. All formulae, however, 
proposed for preparation of solutions of this character have hitherto 
proved imperfect, both in consequence of failure to obtain a pure 
mercuric albuminate, and also from a failure of permanency in the 
solution. Staub's formula, the result of experiments made by Hepp, 1 
may be taken as a sample of the rest. 

R . Hydrarg. chiorid. corros. gr. xviij ; 1 25 

Amnion, chiorid. gr. xviij ; 1 25 

Sod. chiorid. 3J ; 4 

Aq. dest. f|iv; 128 M. 

Dissolve, filter, and add the white of one egg in distilled water sufficient 
to make ,^iv (128.); fifteen minims of the solution contain about one- 
twelfth of a grain (0.005) of the sublimate. 

The treatment of syphilis by mercurial injection has been largely 
extended within the past few years. It should never be ordered 
save in cases specially indicating its employment. With some of 
the other methods employed, it provides for the exclusion of the 
medicament from the gastro-intestinal tract, and accomplishes the 
desired effect with a minimum and exactly mensurable dosage. The 
objections to its systematic employment, outside of hospitals, are 
chiefly the need of a physician or expert to administer the dose. 

The articles employed for hypodermatic injection are well summar- 
ized by Taylor as follows : 

Insoluble salts of mercury. Here are included, calomel in an 
average dose of one grain (0.66) suspended in vaseline oil, salt and 
water, or mucilage and water ; metallic mercury, six to thirty grains 
(0.40-2.); oleum ciuereum, gray oil, mercury with liquid vaseline or 
lanolin, 20 to 50 per cent., 0.05 to 0.1 at each injection; and the 
yellow and black oxides of mercury, corrosive sublimate ; cyanide of 
mercury and combinations of these with the iodide of potassium and 
other salts. 

The antiseptic group, so called, includes the salicylate of mercury. 
A Pravaz syringeful is injected every third day in the gluteal re- 
gion beneath the muscular fascia?, of the following : 

R . Hydrarg. salicylat. gr. xvj-xxiv ; 1060-1.6 

Mucil. acac. gr. viij ; 533 

Aq. dest. f ^ vss ; 175; M. 

1 Traitement de la Syph. par les Inject. Hypoderm. de Sublime. These de Paris, 1872. 



640 DISEASES OF THE SKIN. 

In this group are also included the carbolate or phenate of mer- 
cury; the thymolate (10 per cent, suspensions in fluid paraffin); and 
the benzoate associated with chloride of sodium, two parts, and the 
muriate of cocaine, one part, in five hundred of water. 

The amide group includes formamide of mercury, 1 per cent, solu- 
tions ; glycocoll of mercury, alaninate of mercury, and succinimide of 
mercury, the last two in one per cent, solutions. 

Beside these mercurial preparations, iodide of potassium and iodo- 
form have been subcutaneously injected in a few instances, it is 
claimed, with advantage. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition of 
the gums with inappetence and other characteristic symptoms of the 
ill effects of mercury, including all grades of gastro-intestinal disturb- 
ance, are rarely seen in modern practice, and should never be per- 
mitted to occur in a properly regulated mercurial course. When they 
are produced, the tongue projected from the mouth is usually tumid, 
and exhibits at its lateral borders the imprints of the inner faces of 
the molar teeth. Its surface is also covered in various degrees with 
a thin, dirty-grayish coat; and the odor of the breath is peculiarly 
offensive, being often noticeable at a distance of several feet from 
the patient. In such cases, the food should be liquid and nutritious; 
hot and cold drinks alike should be scrupulously avoided ; and the 
mouth frequently cleansed with washes containing dilute liquor sodse 
chlorinatse, or the chlorate of potassium, or very weak carbolic acid 
in solution. Internally, .the citrate of iron and quinia may be often 
used with advantage ; and, in particularly severe cases, the chlorate 
of potassium to the extent of a drachm (4.) daily. The compressed 
tablets of this salt, each containing five grains (0.33), are available 
for this purpose, being slowly dissolved in the mouth, the medicated 
saliva and mucus being then well diffused over the inflamed buccal 
membrane, tongue, and fauces. The mercurial is to be suspended in 
all cases, and iced water to be interdicted, gangrene having followed 
its use in a few cases. In milder forms, the tincture of myrrh and 
of cinchona, diluted with sweetened water, or honey and water, will 
be sufficient for local medication of the mouth. 

Iodine is chiefly employed in syphilis in the form of the iodide of 
potassium. It possesses some value, without any question, in every 
stage of syphilis, and is thus indiscriminately used by many practi- 
tioners. Its value, however, in so-called late secondary and tertiary, is 
incontestably greater than in the earlier lesions of the disease, and its 
use should be largely restricted to the particular periods in which these 
manifestations appear. Every prudent physician will hesitate before 
ordering, for a disease exhibiting cutaneous lesions, a remedy which 
will positively produce cutaneous lesions in the majority of all 
patients ingesting it. In this connection the reader will do well to 
consult the chapter on Dermatitis Medicamentosa, in which the 
various eruptions produced by this drug are recorded. Thoughtful 
men are beginning, in the light of the present knowledge upon this 
subject, to ask, to what extent the syphilodermata have been in the 






SYPHILODERMA, 641 

past aggravated or obscured by this remedy. He would be indeed 
bold who would attempt to prove that the medicameutous eruptions 
thus excited have not, in the past, figured largely in the catalogue of 
the syphilodermata. 

On the ether hand, the value of the remedy, properly adjusted to 
the age and other conditions of the disease, is more than incontestable, 
it is peerless in its special field. Whether given alone ; or by the 
so-called "mixed" treatment in combination with mercury; or ad- 
ministered internally while a mercurial is introduced by the skin ; or 
exhibited, lastly, by alternation with the metal, in each it finds a 
special value, and may be simply indispensable. It may be given in 
doses of from five grains (0.38) to a drachm (4.) three or four times 
daily after eating, well diluted with water. The larger doses should 
be invariably reached gradually ; should never be employed except 
by special order of the physician, and when the patient is within easy 
reach of the latter; and should always be ordered with the under- 
standing that the patient should diminish or suspend treatment in 
case of unpleasant results. The symptoms of iodism, other than the 
production of cutaneous lesions, such as coryza, oedema of the lids, 
and faucial irritation, are apt to be the result of the first few doses 
ingested, and often bear no relation to the size of the latter. One 
or two grains (0.66-0.133) will, in certain cases, be sufficient to 
produce the most disagreeable effects which, if they are observed 
before the remedy be suspended, may not return with even the largest 
doses. In a few cases, the iodide of potassium produces violent toxic 
effects in any dose, owing to exceptional idiosyncrasy. The author 
has met with several such cases, and has had one patient in his 
charge suffering from an ulcerative tubercular syphiloderm of the 
nose, who was quite unable to tolerate the drug in any form. Both 
the chloride of ammonium and carbonate of ammonium are recom- 
mended for use in combination with the iodide of potassium, as 
increasing its efficiency. The iodides of sodium, ammonium, and 
lithium possess also, without question, some influence over the dis- 
ease, but are for most cases less efficacious than the potassium salt. 
Of the three named above, the iodide of lithium is apparently most 
prompt in its effects. 

There is no combination of mercury with the iodide of potassium 
which is employed more frequently than the well-known u sirop de 
G-ibert," which though first popularized in the St. Louis Hospital, of 
Paris, has been since extensively employed in this country. It has 
been slightly modified to suit the varying tastes of many surgeons. 
It is often ordered in the following formula : 



R . Hydrargyri biniodid. gr. ss-ij ; 

Potass, iodid. gij-viij ; 8-32 

Gentian, syrup, (vel"} 

syrup, glycyrrhiz.) V aaf^ij; 64 

Aq. dest. J 

Dose. A teaspoonful in water after eating. 

41 



033-0.13. 



M. 



642 DISEASES OF THE SKIN. 

The syrup of liquorice disguises the taste better thau most of the 
other syrups used. With the dosage carefully regulated, a few drops 
(ten to fifteen) may be administered with advantage to children. 

The following are indications for the use of the iodide of potassium 
either alone or by the so-called " mixed " method in the treatment of 
syphilodermata : The occurrence (1) of late, tubercular, gummatous, 
or ulcerative lesions ; (2) of formidable symptoms in other portions 
of the body concurrent with early or late, mild or severe syphilo- 
dermata, as, for example, grave ulcerations of the velum or fauces 
with a symmetrical macular eruption, or coincidence of a generalized 
pustular or papular syphiloderm with hemiplegic, aphasic, ocular, or 
renal complications ; (3) of early or late manifestations which either 
assume the so-called " galloping " type, being rapidly succeeded by 
more and more formidable symptoms, or which exhibit the capricious- 
ness of the disease in a reversal of the usual sequence of evolution, as, 
for example, when symptoms usually counted as late phenomena, 
occur within a few weeks after infection and are followed by the early 
symmetrical rashes ; (4) of early or late symptoms occurring in 
cachectic, strumous, or otherwise debilitated patients. The author 
has treated eleven tuberculous patients infected with syphilis ; and 
this experience has led to the belief that in all such cases it is imper- 
ative to dispense with every mercurial dose possible. Mercury is 
assuredly not a tonic in tuberculosis commingled with syphilis. 

The local treatment of the initial sclerosis of syphilis by complete 
excision, lately revived by Auspitz, has been practised since the date 
of his paper in 1879, by Kolliker, Zeissl, Leloir, Chadzynski, 
Mauriac, and others; 1 and the result has proved conclusively that 
such operative interference furnishes no bar to constitutional infec- 
tion. Simultaneous extirpation of all lymphatic glauds in the vicinity 
of an initial sclerosis, with ablation of the latter and a mass of tissue 
about it, have repeatedly proved unavailing to prevent the occurrence 
of systemic infection. Chancres should not be destroyed by caustic 
agents of any character, as the latter are liable to induce either irrita- 
tive or inflammatory effects which may be followed by denser indura- 
tion. Ointments, as a rule, are also objectionable, exception being 
made in the case of hsemorrhagic lesions when the removal of an ad- 
herent dressing is followed by unpleasant consequences. Cleanliness 
with soap and water is of chief importance. After each local bath 
the parts may be dusted with a dry powder such as iodoform, iodol, 
boric acid, calomel, zinc oxide, hydronaphthol, or starch ; or dressed 
with a soft piece of lint, saturated in the lotio nigra, or even better, 
a spirit lotion containing tannin and carbolic or boric acid. Opiated 
washes may be requisite in all painful and ulcerative lesions. When 
a phagedsenic tendency is shown, deep cauterization may be required ; 
and subsequent local employment of solutions of the potassic perman- 
ganate, two to ten grains (0.133-0.666) to the ounce (32.) of water. 

When a primary venereal sore of any character (the initial sclerosis 
of syphilis or the chancroid) actually falls into gangrene or becomes 
phagedsenic or, even in the absence of both of these calamities, extends 

1 See Keyes's later communication on this subject, loc. cit. 



SYPHILODERMA. 643 

rapidly in depth or in superficial area, cauterization should not be 
longer tried. The most effectual treatment of these complications in 
the genital region is by the employment of the continuous hot-water 
bath, aided by antisepsis. The patient remains seated in the bath 
(the water being of the temperature most grateful to the surface and 
with great care maintained at that degree of heat) throughout the 
day, or, in formidable emergencies, if carefully watched, by day and 
night. The bath is left by the patient only for the purpose of 
evacuating the bladder or rectum. Granulation and repair speedily 
set in. The parts are well dusted with iodoform or iodol, whenever 
the patient leaves the water. By this invaluable means, the author, 
in both hospital and private practice, has succeeded in obtaining cica- 
trization of extensive ulcers which had reached over the penis half 
way to the pubic region. 

Local treatment of the syphilodermata may be demanded, either 
by reason of their appearance on exposed surfaces, such as the face and 
hands, or by reason of their obstinacy or threatening character, as 
when they are ulcerating rapidly. Macular and papular lesions of 
the face may be treated by local applications of the five per cent, 
oleate; mercurial ointment, one to two drachms (4.-8.) to the ounce 
(32.) of cold cream or vaseline ; the red oxide, two to four grains 
(0.133-0.266) to the ounce (32.) ; or the ammonio-chloride, half to 
one scruple (0.666-1.33) to the ounce (32.) of ointment. Lotions of 
the bichloride, one to two grains (0.066-0.133) to the ounce (32.) of 
cologne, are also efficient. These preparations will be found much 
more valuable if used at night before retiring, and left upon the face 
during the hours of sleep. Each is well preceded by hot bathing of 
the face for several minutes, as in the preparatory treatment of the 
same region in acne papulosa, and indeed the sulphur preparations 
employed for the relief of that disease will at times be found useful 
also in the local treatment of the syphilodermata. 

The hot ablution is particularly useful in the treatment of the 
scaling and frequently fissured lesions of the palms and soles, the 
pain of which in severe cases is greatly alleviated by this treatment. 
After the epidermis in these parts has been well macerated, the hands 
or feet should be thoroughly dried, and the mercurial, tarry, or other 
salve well rubbed in. The glove or stocking should then be drawn 
over the part. 

Secreting condylomata, flat papules, vegetations, etc., also require 
bathing in soap and water, especially when situated at the mucous out- 
lets of the body or on the scalp. When the secretion is offensive in odor, 
boric or carbolic acid, thymol, or chlorinated soda should be added 
to the lotion. Cleanliness is indeed more essential to the syphilitic 
patient, man or woman, than to the healthy. After such cleansing 
or disinfecting ablution, the parts should be dressed with a powder, 
such as dry calomel, iodoform, iodol, hydronaphthol, bismuth, the 
zinc oxide, salicylate of soda, or starch. Vegetating lesions of these 
regions may require also pencilling with a crayon of the nitrate of 
silver. Ointments, as containing grease, are decidedly objectionable 
for this purpose. 



644 DISEASES OF THE SKlN. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be re- 
moved, either by the oil and soap and water treatment, or by the 
dermal curette, after which the underlying ulcers should be thor- 
oughly cleansed, pencilled with nitrate of silver, filled with powdered 
boric acid, iodoform, iodol, or calomel, or touched with a five to 
twenty per cent, solution of carbolic acid, and then dressed with a 
dilute ointment of the nitrate of mercury, one to two drachms (4.-8.) 
to the ounce (32.). Large syphilitic ulcers are often encountered on 
the surface of the lower extremities, especially the legs, and in this 
situation elastic compression by the rubber bandage will greatly 
accelerate their cicatrization. 

The syphilodermata are in general particularly amenable to the 
action of the mercurial vapor bath, which may be regarded as exert- 
ing upon them both a local and constitutional influence. Those 
existing upon the face are thus benefited by exposure to the metallic 
vapor in the " head-piece " arrangement already described. The 
patient may also less comfortably avail himself of the same local 
treatment, by holding the breath and exposing the head and face for 
a few minutes at a time to the fumes of the mercury beneath the 
blanket, in the plan described as practicable at the bedside. 

It is within reasonable bounds to say, that the syphilodermata, if 
treated locally by the measures described as useful in non-syphilitic 
cutaneous affections of similar type, will always proceed to a satis- 
factory involution, if the general treatment also be skilfully ordered. 

Prognosis. — The prognosis of syphilis may be said to be in general 
favorable, the popular opinion on the subject being at variance with 
fact. Benignant syphilis may even disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. 
The element of treatment, both as to the character of the latter and 
the period of its continuance, enters more largely into the estimate 
upon which a prognosis rests than in most other disorders exhibiting 
cutaneous symptoms. The syphilis which is untreated, whether be- 
cause of a failure to recognize its real character, or of ignorance, pov- 
erty, neglect, or extravagance in dissipation, is usually grave. The 
same may be said of syphilis occurring in strumous, tuberculous, and 
cachectic subjects, those enfeebled by age, by other diseases, by chronic 
alcoholism, or by sexual excesses. Hereditary syphilis is by far the 
gravest form, not merely because of the tender age of its victims, but 
because these, at the earliest period of their lives, are burdened by a 
disease which may first attack organs essential to life. 

The majority of adult American patients sooner or later get rid of 
all active manifestations of the acquired disease, marry, and beget iu 
the end sound children. 

Chancroid. 

This term has been very generally adopted in this country for the 
purpose of designating the virulent, local, contagious ulcer of the 
genitals, designated also as the " simple," " soft," " non-infecting " 



CHANCROID. 645 

chancre, the chancrelle of French authors. It has no relation to 
syphilis, nor to the neoplasinata with which syphilis is commonly 
classified. As it is, however, a disease with which the initial sclerosis 
of syphilis may be confounded, and is also, not merely a venereal 
lesion, but one which may be encountered upon the skin as well as 
the mucous surfaces, it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the lesions 
of vaccinia or of herpes zoster. They are thus stamped with special 
and readily recognized characteristics, differing in this respect from 
the various modes in which the first lesion of syphilis may declare 
its nature. The virus of the disease, for such it must be termed, is 
one sui geyieris, and derived exclusively from lesions of like charac- 
ter. That virus is contained in a purulent secretion, and is capable 
of transmission by inoculation and auto-inoculation. After such 
successful inoculation, there is no period of incubation. The results 
of experimental generation of the virus in human subjects indicate 
that the pathological process which it awakens can be determined 
within twenty-four hours after its introduction within the skin. At 
times, after accidental inoculation, eight and ten days elapse before 
the lesion of the disease is manifested, cases where presumably the 
virulent secretion has remained pocketed in the orifice of a follicle 
or a fold of mucous membrane, where its irritant effects have finally 
opened an avenue for its deeper ingress. When typically developed, 
the chancroid is seen to be a pustular lesion, frequently multiple, 
of roundish outline, beginning as a pin-head sized, turbid, vesico- 
pustule, rapidly enlarging to a pea- or bean-sized, well developed, 
projecting, yellowish, globoid elevation of the epidermis, filled 
with greenish-yellow pus. When located in furrows or depressions of 
the surface, it may have a linear, oval, or even a dumb-bell shape, the 
latter in consequence of extension from a sulcus to overlying folds. 

Clinically, the roof-wall of this pustule is not frequently encount- 
ered, the lesions from the first exhibiting the ulcers from which the 
pustules described above invariably rise. These ulcers vary with 
the shape of the superimposed pustules, being round, ovalish, or 
linear, occasionally irregular in outline, with sharply defined or cut 
edges ; uneven, pus-bathed floor ; faiut pinkish areola ; supple, non- 
indurated base; abundant puriform secretion; and are accompanied 
by pain or not, according to the degree of inflammation present. In 
consequence of the auto-inoculability of the discharge, the ulcers 
frequently give rise to others in the vicinity, as w T heu the prepuce lies 
in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of a pea 
or bean in the course of from ten to fourteen days ; then remain in 
an indolent and suppurative condition, showing no tendency to heal 
for a fortnight or three weeks ; and finally granulate, exhibiting the 
ordinary phases of repair. The resulting cicatrix is either transitory 
or, more often, indelible. In exceptional cases the ulcer spreads 
widely. In the groin, it may attain a diameter of several inches ; 
its floor secreting scantily ; its edges, lurid, undermined, purplish, or 



646 DISEASES OF THE SKIN. 

ragged ; its color, reddish, bluish, purplish, or leaden ; fistulous tracts 
and sinuses filled with an ichorous sero-pus, radiating in dependent 
situations ; its base, densely iudurated ; its career, prolonged for 
years, and inducing finally a systemic cachexia not different from 
those observed in all chronic ulcerations of severe grade. In yet 
other cases, the occurrence of gangrene, or phagedena, changes the 
features of the lesion to those of other ulcers undergoing similar 
metamorphosis. 

Chancroids occur upon all exposed mucous surfaces of the geni- 
talia of both sexes, upon the integument of the penis, scrotum, labia, 
thighs, fingers, perineum, peri-anal region, and, very rarely indeed, 
upon the face. In consequence of their tendency to relapse, abundant 
contagious secretion, and auto-inoculability, they are more frequently 
encountered than the primary syphilitic lesion, among the filthy, 
the poor, and the classes that frequent hospitals and dispensaries. 
Among the wealthy, the well-to-do, and the cleanly, this order of 
frequency is reversed. 

The chancroid ulcer is also much more frequently complicated by 
surgical accidents than is the infecting lesion of syphilis. This is 
partly due to the prevalence of an ulcerative type in all its manifes- 
tations, and in part to its situation. Thus it is often accompanied by 
severe inflammatory symptoms, which may be aggravated both by 
phimosis and paraphimosis, occurring with stenosis of the preputial 
aperture, or with a long, lax, and redundant foreskin. Phagedaena 
is also a formidable complication, whether of sloughing or serpigi- 
nous tendency, the lesion in each case losing its chancrous character- 
istics. It is evident also that the disease may coexist with others of 
a different character. Thus a single point may be simultaneously 
inoculated with chancroidal and syphilitic virus ; the former, without 
an incubative period, followed rapidly by a pustular or ulcerative 
lesion ; the latter, after its incubation is complete, producing the 
characteristic symptoms of an initial sclerosis. Chancroids may also 
be found coexisting with secondary and tertiary syphilitic lesions of 
the genitals, with vegetations, with blennorrhagic discharges and 
balanitis, with pediculi of the pubes, and with herpes progenitalis. 
Patients of the class exhibiting these lesions, not infrequently present 
themselves at public dispensaries with three or more of these concur- 
rent disorders. 

One of the most serious complications of the chancroid is its 
association with a specific lymphangitis, peri-adenitis, or adenopathy. 
In such case, the lymphatic trunks connected with the lesion become 
inflamed, indurated, and irregularly corded, with the overlying 
integument often oedematous, reddened, and painful. The chancrous 
process in these vessels rarely terminates by suppuration. The bubo 
of chancroid is more common, and may be either a sympathetic 
adenopathy, resulting from the severity of the process at the site of 
the lesion, or virulent and due to the transmission of an inoculable 
pus to one or more of the glands in near connection with the source 
of the trouble. These gland complications may coexist in one person, 



CHANCROID. 647 

in men more often than in women, and in about one of each four or 
five cases presented to observation. When inoculable pus has been 
formed in a neighboring gland, the latter is at once converted into 
the seat of an abscess, the pus of which, whether evacuated sponta- 
neously or by the knife of the surgeon, speedily inoculates the lips 
of the wound through which exit has been obtained. The wound 
and contiguous abscess cavity then form a large chancroidal ulcer, 
usually inguinal in situation, as the glands in this locality are 
nearest the most frequent seat of the lesion. Such an inguinal ulcer 
discharges a greenish-yellow pus, often commingled with blood ; its 
borders are undermined, thin, livid or purplish, and ragged ; its 
floor is irregular, sloughy, and often covered by nodules representing 
the debris of glandular structure ; from it depart sinuses traversing 
the tissues in the vicinity, often downward to the thigh, occasionally 
upward over the belly. When occurring in strumous and cachectic 
subjects, or when long neglected or mismanaged, the resulting dis- 
order is one of the most serious character, and may surpass in dura- 
tion and severity certain of the varieties of lupus and epithelioma. 
The author has had under his charge a man, the skin of whose right 
thigh, from the groin to the knee, was completely riddled by sinuses 
resulting from a chancroidal bubo which had occurred several years 
before. A few years ago the author was called in consultation to 
visit a woman in wretched health with an indolent ulcerative lesion 
of this sort in the right groin, which had lasted for five years. 
Despairing of relief, and before a change of treatment could be in- 
stituted, she hanged herself by the neck till she was dead. 

Facts of this sort have an important bearing. It is true that 
syphilis is a constitutional disease, and usually occurs but once in a 
lifetime. It is equally true that the chancroid is the evidence of a 
local and non-systemic disorder, producing constitutional effects only 
as may all other local affections of chronic course and severe grade. 
But it is a grievous blunder to suppose for these reasons, that the 
latter is the milder of the two maladies. Many of its consequences 
are very much more severe, aud some of them even more malignant, 
than the average of syphilitic sequelae, and even, as indicated above, 
worse than some forms of other diseases usually counted as malig- 
nant. Greater attention should be generally directed to the truth 
respecting the comparative gravity of the two diseases, as there is 
widespread ignorance of the real facts. 

Chancroid is to be distinguished from syphilitic chancre, but no 
skill, however great, and no experience, however wide, will enable 
the diagnostician, even when typical chancroid is present, to assert 
that syphilis will not follow, until the longest incubative period of 
the initial sclerosis of the last-named disease has elapsed without 
production of suspicious symptoms. The rule which necessarily fol- 
lows is imperative, and, being too frequently ignored, a great deal of 
bitter disappointment on the part of the infected individual, and of 
keen mortification on the part of the physician, has naturally re- 
sulted. No PATIENT SUFFERING FROM A CHANCROID CAN BE 



648 DISEASES OF THE SKIN. 

SAFELY PROMISED IMMUNITY AGAINST SYPHILIS TILL TWO MONTHS 
AND A HALF HAVE ELAPSED AFTER THE DATE OF LAST EXPOSURE. 

Subject to this essential reserve, the diagnosis rests upon the pustular, 
ulcerative, aud discharging features of the chancroid, its failure to 
indurate at the base, its auto-inoculability, its appearance without 
previous incubation, its more formidable localized expression of 
disease, and the characteristics of the accompanying adenopathy. 
The short-lived, superficial vesicles of herpes progenitalis, often 
accompanied by tingling and painful sensations, with sequela? in the 
form of equally superficial, epidermal excoriations, are not to be con- 
founded with chancroids ; and yet it must be remembered that these 
lesions may also precede or accompany any form of venereal disorder. 
Chancroids are also to be distinguished from secondary and tertiary 
lesions of the genitals, and from non-syphilitic vegetations and 
molluscum epitheliale of the same region. 

The pathology of the chancroid, though illustrated by the re- 
searches of Biesiadecki, Auspitz, aud Unna, is yet not understood to 
an extent that will explain its specific character. The micro-organ- 
isms discovered in all coccogenous lesions are usually abundant and 
readily demonstrable. Those recognized by Ducrey, of Naples, 1 were 
short and thick bacilli measuring 1.46 x 0.50 micromillimetres. These 
observations were confirmed by Krefting, of Christiania ; 2 while those 
discovered and claimed as pathogenic by Unna (his observations being 
later confirmed by Quinquaud and Nicolle) occur in the form of 
twisted coils and chains, measuring 1.25 x 0.33 micromillimetres. The 
etiological value of these observations remains to be determined. 

Anatomically, there is disclosed by the microscope a uniform, 
dense infiltration of the corium with elements which undoubtedly 
represent inflammatory metamorphosis of the connective tissue of 
the derma ; degenerative changes where the ulceration has proceeded 
superficially ; enlargement of vessels from thickening of their walls, 
often with diminished lumen ; and relatively intact rete and corium 
at the lateral borders of the ulcer. This fully confirms the inferences 
suggested by a clinical study of the disease. Many roundish, cir- 
cumscribed, clean-cut ulcers with purulent floors occur upon the 
skin, which bear no relation to the chancroid disease. It is the 
history and career of the latter which stamp it with an individuality 
of its own. It is not the form and appearance of its pus elements, 
but their power and potency, which make them singular. 

The routine treatment of chancroids is by destructive cauterization 
with nitric or sulphuric acid. Keyes recommends a previous appli- 
cation of pure carbolic acid, in order to benumb the part and render 
the subsequent application less painful. If employed at all, the latter 
should be carefully wiped from the sore before the subsequent cauter- 
ization, as the two acids will explode if suddenly united. As the 
slough separates, the ulcer may be dressed in accordance with the 
general principles governing the treatment of simple granulating 
wounds. Vinous, carbolated, and opiated lotions, powders of boric 

1 Congres Internat. de Derm, et de Syph., Paris, 1889. 

2 Arch. f. Derm. u. Syph., Erganzungshefte, 1892, p. 41. 



LEPRA. 649 

acid, iodoform, iodol, calomel, bismuth and starch, simple unguents, 
and the interposition of a pledget of borated cotton between all 
affected and sound tissues — these in most cases suffice to insure relief. 
Pencillings with the nitrate of silver, though ineffective for the pur- 
poses of cauterization, often answer a good purpose in hastening re- 
pair. The prepuce may require division or circumcision. 

For the grave and extensive ulcerations, accompanied or not by 
phagedena or gangrene, there is no treatment at all comparable in 
value with the hot- water bath of an average temperature of 98° F. 
For the details of this method, the reader is referred to the paragraph 
devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, require 
the surgical treatment appropriate for the relief of those conditions. 
For the accompanying adenopathy in chancroid disease, before sup- 
puration has occurred, rest is essential, with laxatives internally and 
gentle local compression. When there is great heat and tenderness, 
a few leeches may be applied. After pus has formed, it may be 
evacuated with the aspirator needle, or by a free incision in the long 
axis of the swelling, followed by curetting of the abscess cavity and 
the usual antiseptic dressings. Constitutional treatment by iron, 
quinine, cod-liver oil, and the employment of a generous diet with 
milk, malt liquors, or wines, is often required in broken-down and 
debilitated persons. 

The Prognosis, in uncomplicated cases, is generally favorable. The 
scar left by a suppurating glaud in the groin is indelible, but be- 
comes less and less conspicuous with years. Sloughing and gan- 
grenous sores usually leave deforming cicatrices, especially when 
occurring at the apex of the glans, to which they are apt to give a 
peculiarly truncated shape. A just reserve should be made in all 
cases complicated with syphilis or extensive fistulous sinuses ; the 
latter, as described above, often persisting for years. 



Lepra. 

Gr., leirpbg, scaly. 

(Satyriasis ; Elephantiasis Grsecorum ; Leontiasis ; Lepra Arabum ; 
Leprosy. Fr., Lepre ; Gee., Aussatz ; Norweg., Spedalskhed.) 

Statistical frequency in America, 0.032. 

Lepra is an infectious, parasitic disease, of exceedingly chronic course, capable 
of involving all of the organs and tissues of the body, characterized by cuta- 
neous pigment alterations, disordered or abolished sensation, tubercles or other 
circumscribed or diffuse infiltrations, bullae, ulcers, cicatrices, atrophies, destruc- 
tion of deep tissues, loss of the appendages of the skin, and the ultimate pro- 
duction of a cachexia which usually terminates fatally. 

Symptoms. — In whatever form leprosy may be ultimately mani- 
fested, its appearance is usually preceded by the prodromic symptoms 



650 DISEASES OF THE SKIN. 

generally recognized as the precursors of severe constitutional dis- 
ease. These are : anorexia ; chills, alternating with mild or severe 
febrile attacks ; depression ; gastro-intestinal disturbance ; and insom- 
nia. Their duration is exceedingly variable ; in some cases, patients 
will remember that these or similar symptoms preceded for years the 
earliest outbreak of the disease. In yet others, but a few weeks' 
interval occurs between the prodromic and successive stages of the 
disease. It is worthy of note that the character of the former fur- 
nishes no clew to the severity and type of the latter. 

The earlier cutaneous lesions of leprosy are tubercular, macular, or 
bullous. These may be coincident or successive, or one or two of 
these types may so far predominate that another may be either alto- 
gether wanting, or possess, in the general pathological history, but a 
trifling significance. It has thus been customary to make an entirely 
artificial distinction between cases of leprosy, by assigning them to 
three varieties, tubercular, macular, and anaesthetic. It will be 
understood, then, in separately considering these three forms, that 
the distinction between them is useful simply for the purposes of 
clinical classification ; that mixed cases of the disease occur which it 
would be difficult to assign to either variety exclusively ; and that 
each merely represents a predominance of certain lesions at one patho- 
logical epoch. It should be noted also that the symptoms of leprosy 
are particularly remarkable for their polymorphism, a wide variation 
often existing between the character of two or more lesions which at 
any given moment are apparent. This is largely owing to the fact 
that leprosy is a general and constitutional disorder, the cutaneous 
symptoms of which are simply its surface markings. 

[A.] Lepra Tuberosa. 
(Tuberculated, or Nodulated, Leprosy.) 

Tubercular leprosy commonly begins in the skin with macular 
lesions. These are bean- to tomato- sized, reddish, brownish, or 
bronze-hued patches ; roundish, oval, or irregular in contour ; and 
occurring upon the face, trunk, or extremities. The skin covering 
these is either smooth and shining as if oiled, or moderately infil- 
trated and elevated. 

After a period ranging in duration from weeks to years, tubercles 
rise from these maculations, varying iu size from a pea to a nut, 
though they may be as large as a tomato. They are yellowish, red- 
dish-brown, or bronzed in color, often shining as if varnished or 
oiled, covered with a soft, natural, or slightly desquamating epider- 
mis, roundish or quite irregular in contour, and either isolated or 
grouped. Numbers of very small and ill-determined nodules may 
often be recognized by careful examination of the skin in the 
vicinity of those fully developed. They may be either cutaneous or 
subcutaneous in situation, and softish or quite firm to the touch. 

The site of predilectiou of leprous tubercles is the face ; and their 
massing in great numbers upon this region produces the characteristic 



LEPRA 



651 



deformity of the countenance which has given to the disease one of 
its names, Leontiasis (face of a lion). In such faces the tubercles 
are ranged in parallel series above the brows, down the nose, over 
the cheeks, the lips, and the chin. In consequence of the infiltration 
and development of the lesions, the brows deeply overhang the globes 
of the eyes, the lids become affected with a partial ptosis, the lips 
pout, and the ears are so studded with tubercular masses as to project 
from the side of the head. The trunk and extremities, including the 
palmar and plantar surfaces, are then usually to a less degree 
involved. Occasionally, indeed, with extensive development of tuber- 
cles upon the face and ears, there may not be more than from five to 
fifty upon the rest of the body, and these either widely dispersed and 
isolated, or agglomerated in a single, hard, flat, elevated plaque of 
infiltration upon the elbow or thigh. 



Fig. 




Lepra tuberculosa. (After Danielssen and Boeck.) 

With these cutaneous lesions there is often involvement of the 
mucous surfaces, especially the velum palati and larynx. In the 
case of a leper affected with the tubercular form of the disease whom 
the author exhibited at the clinic in 1879, l there was very marked 
gruffness and hoarseness of the voice, and the larynx and velum were 
studded with pin-head to pea-sized, ashen-hued tubercles. Others 
may form upon the conjunctiva and the Schneider ian membrane. 

These tubercles may degenerate into ulcers ; or undergo resorption 
and disappear, leaving in their place pigmented atrophic depressions ; 
or lose their shape in consequence of partial resorption. I have thus 



1 Chicago Med. Journ. and Exam, 
ance of larynx. 



December, 1879, with cut showing laryngoscopy appear- 



652 



DISEASES OF THE SKIN. 



seen a large plaque flatten centrally till an annular disk was left to 
indicate its former site. 

It should be borne in mind, however, that the course of the disease 
is exceedingly slow, and that years may elapse before these several 
changes are accomplished. The disease, indeed, often appears to be 
quiescent for months at a time, after which with the occurrence of 
fever, acute or subacute manifestations appear, and a relatively rapid 
progress is made toward a fatal conclusion. Long before the latter 
is reached there are usually, in tubercular leprosy, intermingled symp- 



Fig. 80. 




Tubercular leprosy (from a photograph of a leper in the Sandwich Islands). 



toms of anaesthetic type, such as the occurrence of bullae or of anaes- 
thetic patches with and without pigmentation. Toward the last, the 
mutilations effected by the disease may result (Lepra Mutilans). 
Phalanges of the fingers or toes, whole digits, an entire hand or foot 
may then become partially or wholly detached by ulcerative, atrophic, 
or other degeneration of skin, bones, and ligaments, hastened or not 
by intercurrent attacks of lymphangitis, erysipelas, septicaemia, and 
irritative fever. 

The stadium of this type of the disease may extend through ten 



LEPRA. 653 

or even more years. After its full development, the peculiarly 
dejected countenance of the leper, with his leonine facies and general 
appearance of cachexia, are highly characteristic. 

[B.] Lepra Maculosa. 

This form of the disease is chiefly distinguished, as its name implies, 
by its macular lesions. These have the general character of those 
described as preceding the appearance of the leprous tubercles. They 
are diffused or circumscribed, roundish or irregularly shaped, and in 
color yellowish, brownish or bronzed, often shining or glazed. They 
may be infiltrated or not ; and in the former case, be slightly raised 
from, or on a level with, the adjacent tissues. At times, they appear 
as lardaceous deposits in the skin, whitish, reddish, or even blackish 
in color, with a telangiectasic border. These patches are usually at 
first hyper aesthetic, but finally become quite insensitive, so that a 
lancet can be thrust deeply into them without producing the slightest 
sensation. 

The pigment variations in macular lepra are noticeable. At times, 
a distinctly anaesthetic patch may be readily limited both by its lack 
of sensation and of normal color ; at others, either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus a palm- to platter-sized, texturally unaltered area over the thigh 
or belly, may suggest a vitiligo by its relatively slight pigmentation 
and its distinct contour, beyond which are sepia to deep-chocolate 
tints, gradually fading toward some adjacent and similarly involved 
patch. Yet this area will often differ materially from that of vitiligo 
in other respects. Every inch of the former may be totally insensi- 
tive to the prick of the lancet, and be moreover of a dull, tawny, 
yellowish, or parchment-like hue, never having the peculiar milky- 
white tinge of vitiligo. Again, this anaesthesia may extend widely 
beyond the line traced by the pigmeut anomaly, or even within the 
latter vary, islets of skin capable of perceiving sensation, being in 
cases here and there discernible. 

[C] Lepra Ansesthetica. 

This clinical type may be, as has been described, commingled in its 
symptoms with each of the others. With and without these, how- 
ever, there is commonly noted first an eruption of bullae, bean- to large 
nut- sized, with a roof- wall constituted of the entire thickness of the 
epidermis, filled with a clear tinted or blood-mixed serum, occurring 
usually upon the extremities. The cicatrices which follow these are 
atrophic patches, often far greater in extent than the base of the 
original bulla ; whitish, shining, glazed, or better .described as of a 
tint suggesting the hue of mica ; circular in outline, forming also the 
dumb-bell figure by coalescence or juxtaposition. These are always 
anaesthetic ; and may coexist with macular and anaesthetic patches 
upon the trunk or other portions of the body. Neither those of the 



654 



DISEASES OF THE SKIN 



one class nor of the other, are, however, disposed over the surface of 
the body in lines, bands, or curves corresponding to the distribution 
of the cutaneous nerves. The greatest irregularity is displayed ; 
asymmetry is the rule. Occasionally, however, the ulnar and other 
nerves accessible to the touch, are recognized to be tumid, tender, 
insensitive, or as rigid as indurated cords. General atrophic cuta- 
neous symptoms follow these ; the skin becomes dry and harsh ; there 
is manifestly little or no sebaceous product ; the sweat is scanty ; the 
muscles atrophy ; the hairs fall ; the lymphatic ganglia enlarge ; the 
skin of the face seems tightly stretched over the bones. As a result 
of deforming atrophy of the lids, epiphora and consequent orbicular 
changes ensue, and the parted lips permit constant escape of saliva. 

Fig. 81. 




Anaesthetic leprosy with mutilating results (from a photograph taken of a leper in the 
Sandwich Islands). 



The fingers are half drawn into the palm of the hand ; the nails are 
distorted, and, later, ulceration occurs. The ulcers are irregular, oval, 
roundish, linear ; covered with thin, blackish, flattened, tenacious, 
never rupioid, crusts ; their bases are soft ; their floors covered with a 
pultaceous debris often mixed with blood ; the whole usually insensitive 
to every foreign body and external application. Lastly the symp- 
toms of lepra mutilans may occur, digits, or portions of the carpus, 
metacarpus, or corresponding parts of the foot, being detached from 
the bodv. 



LEPRA. 655 

Death may ensue at any time during the course of the disease from 
septicaemia, exhaustion, or any of the intercurrent affections to which 
a patient in such condition is particularly disposed. Thus a leper 
was lately accidentally choked to death in San Francisco by some 
perversion of the function of deglutition. The disease, however, in 
this form is said to last from eighteen to twenty years, and is thus 
less rapidly fatal than the tubercular variety. 

Considering the several clinical varieties of leprosy named above, 
and the mixed forms resulting from a commingling in some cases of 
the features of all varieties, the result is merely an analysis of the 
symptoms in an enormous clinical field. There are not, in fact, any 
forms or varieties of this disorder ; there is but one disease which 
exhibits itself in widely differing manifestations, and these at one 
time and in one country assuming a predominant phase, while with 
a different environment and race, other phenomena appear. Thus 
lepra tuberosa is reported in from fifty to seventy-five per cent, of 
patients affected with the disease in the north of Europe, and in from 
ten to twenty per cent, of those in tropical countries ; while anaes- 
thetic lepra in the geographical limits last named, is represented by 
two-thirds of patients, and in northern latitudes by less than one- 
third. " Mixed forms " are less often reported than others, but are 
as a matter of fact the more often observed. The reason for this 
apparent anomaly lies in the fact that really pure cases of any form 
are actually rare. It is best to look upon the expressions of lepra 
as it is accepted to regard the phenomena of syphilis : in each there 
is a single morbid principle ; there are in both no true varieties ; and 
the external symptoms differ chiefly because of special accidents of 
environment, race, or individual peculiarities. 

Looking at the variant symptoms of lepra, a wide range occurs in 
all stages. In the evolution of the disease there is a usual order of 
fever, eruptive symptoms, and ulcerative or destructive sequelae. 

In the prodromic period there are often chilliness, profuse diaphoresis, 
insomnia, inappetence, diarrhoea, vertigo, and even a bullous efflores- 
cence upon the surface. These prodromata are rarely wanting, and, 
after lasting for weeks, months, or years, are followed by sensations 
of chilliness, with remitting or intermitting febrile symptoms, the 
temperature rising from 100° to 105° F. The tongue becomes of a 
reddish hue, the listlessness and sluggishness continue, and the typi- 
cal cutaneous lesions of the disease (leprous spots) appear, commonly 
on some portion of the face, with or without oedema. In some cases 
the prodromic symptoms and fever and chilliness are either absent or, 
what is far more probable, unnoticed, and then the disease may be 
first recognized by pains of a lancinating character, tenderness, and 
aching, especially along the course of the ulnar, peroneal, median, 
saphenous, or other nerves ; or the result may be hyperaesthesia, 
anaesthesia, or pricking, tingling, and similar sensations in regions 
supplied by special nerves. The greatest variation is observed in the 
length of time during which these early symptoms, with more or less 



656 DISEASES OF THE SKIN. 

vagueness of expression, exist. Later, tubercles, nodules, bullae, 
macules, hyper aesthetic and anaesthetic patches appear with and 
without a gradual development of other and non-cutaneous symp- 
toms, paralysis, exaggerated tendon-reflexes, atheromatous papules 
upon the palpebral membranes and cornea, at times resulting in an 
ulcerative keratitis ; nodules over the chest, genital regions, and ex- 
tremities, as well as upon the mucous surfaces of the mouth and 
respiratory tract, the voice becoming raucous, while recrudescences 
of the disease occur either along the one (tubercular) or the other 
(anaesthetic) line toward the final stages of degeneration and mutila- 
tion. 

The disease is seen in all typical forms, even in regions where 
leprosy is least prevalent. There may be a genuine leprous pachy- 
dermia with enormous increase in the volume of the hands and feet, 
accompanied by severe onychia and paronychia, and deep ulcera- 
tions about the nails. In some cases, tumefaction of an entire limb 
results, strongly resembling an elephantiasis. The nose may be stuffed 
with leprous tubercles, and a large number of cutaneous symptoms 
of the most varying type develop in and upon the leprous skin as 
the result of secondary infection, of accidents, or of invasion by pus- 
cocci, etc., for it must be remembered that in the mass of cases the 
leprous belong to the filthy and impoverished classes of society. 
Thus there are often developed eczemas, erythematous and achromic 
and hyperchromic spots and disks, annular lesions resembling those 
seen in syphilis, bullae rapidly becoming gangrenous (erytheme poly- 
morphe l£preux, bulleux, et escharotique, of Leloir), nodules of the 
usual size and hue of those in lepra (pin-head to nut, pigmented, 
reddish-brown, copper-tinted, glazed, shining as if oiled), and enor- 
mous infiltrations within and below the derma, even the production 
of large tumors of leprous tissue. 

The generative apparatus may be seriously involved, the uterus, 
Fallopian tubes, and ovaries being the seat of leprous nodules or 
diffuse lepromatous infiltrations ; as may be also the testicles, pros- 
tate gland, and penis. The breasts are 
fig. 82. often stuffed with tubercles; but they, as 

also the other organs named, may simply 
waste under the influence of the disease. 
The sexual power is retained longer than 
is commonly believed. In the colored 
races the eruptive symptoms are tinted in 
yellowish and reddish shades, a result due 
to contrast with the hue of pigmented 
skins. 

Etiology. — Leprosy is a contagious and 
lepra tuberculosa. (One of the infectious parasitic disorder produced by 
author's cases.) the bacillus leprae. Secretions of a leprous 

patient containing these bacilli or their 
spores are the usual vehicles by which the disease is transmitted 
from man to man. The question of the inheritance of leprosy may 




LEPKA 



657 



be regarded to-day as in much the same position as that relating to the 
inheritance of tuberculosis ; no foetus, no newly-born living child 
has been known to exhibit the symptoms of either disease. Men are 
more often affected with the disease than women. Infection is more 
common after the second decade, though children are occasionally 
found among its victims. 

The geographical distribution of leprosy is widely extended. In 
countries where it has not previously existed, its appearance is in- 
variably due to the infection of sound individuals by lepers first 
exhibiting symptoms in a country where the disease is prevalent. 
Neisser formulates the law of its prevalence by stating that the 
number of lepers in any country bears an inverse ratio to the laws 
executed for the care and isolation of infected persons. 

The disease exists in the interior and throughout the seaboard regions 
of Africa, including Egypt ; in Arabia, Syria, Persia, China, Japan, 
and India ; in the islands of the Mediterranean, Black, Caspian, 
and China Seas, of the Indian Ocean, and of the Australian Archi- 
pelago ; in Norway and Sweden, Iceland, Russia, Turkey in Europe, 
Spain, France, Portugal, Greece, and Italy ; and sporadically in Ger- 
many, England, and the smaller European States ; in Xorthern, Cen- 



Fig. 88 



Fig. 84. 




- 



y^- 



' 




Larynges of lepers affected with lepra tuberculosa. (Elsberg*s cases.; 

tral, and South America, and the TTest India Islands. In our own 
country, special attention has been directed to the subject by the 
existence of the disease in an epidemic form in the Sandwich Islaods. 
with which the Pacific States sustain close commercial relations ; by 
its occurrence among the Chinese immigrants in San Francisco and 
other portions of California ; by cases reported from Xew Orleans 
by Burns, 1 Bemiss, 2 Jones, 3 and Solomon, 4 and by various reports of 
sporadic cases observed in Minnesota, Maryland, Illinois, Nebraska, 
Xew York, and other States of the Union, by Gronvold, Hoegh, 
Bend eke, Kobe, Piffard, Elsberg. Atkinson, the author, and others, 
collected by the Committee on Statistics of the American Dermato- 
logical Association, and presented to that and other bodies in special 



1 Arch, of Med.. December. 1881. 
3 Ibid., March, 1878. 



- X. 0. Med. and Surg. Journ.. April. 1S80. 
4 Trans. Louis. State Med. Assoc, 1^79. 

42 









658 DISEASES OF THE SKIN. 

papers. Drs. White and Graham, of the same committee, have also 
contributed to the history of the colony of lepers which has long 
existed in Tracadie, in the province of New Brunswick. 

With this wide geographical distribution, the disease exists en- 
demically in certain countries, and also in certain regions of the 
same country, with greater frequency than in others. All attempts, 
however, to connect its origin with malaria, with a residence near 
inundated sea marshes, with the ingestion of a diet consisting 
largely of fish, or of a diet from which salt has been largely 
excluded, have failed of any recognized success. It is true that 
probably the larger number of all living lepers are those who have 
been poorly fed, and otherwise subjected to the most insalubrious 
of influences, but the disease also attacks, though far more rarely, 
persons whose social position and hygienic surroundings are of the 
best. It occurs in both sexes and at all ages ; and, despite all efforts 
to show the contrary, bears no relation to syphilis. Lepers become, 
however, syphilitic if infected with that disease, precisely as they may 
and do acquire variola, varicella, morbilli, erysipelas, and phthisis. 
The Hebrew Scriptures are often interpreted as showing that the 
disease among the Jews in Palestine was regarded by them as con- 
tagious, and so treated. The modern student of these writings will, 
however, be convinced that this interpretation is erroneous. The 
leprosy of the book of Leviticus not only includes lepra, as that term 
is understood to-day, but also psoriasis, scabies, and other cutaneous 
affections. The leper in the eye of the Mosaic law, was ceremonially 
unclean, and capable of communicating only a ceremonial unclean- 
ness. Several of the narratives contained in these books bear witness 
to the fact that the Oriental leper was occasionally seen doing service 
in the court of kings, and even in personal communication and con- 
tact with officers of high rank. 

Pathology. — The histological element of leprosy is represented by 
a new growth of round, oval, uni- or bipolar or otherwise irregularly 
contoured bodies. These originate either in the connective tissue of 
the skin, mucous membranes, adventitia of the vessels, or nerve- 
sheaths, or are derived, as Schmidt has shown, from the epithelium, 
endothelium, and even the fat elements of the affected tissue. These 
are single, or grouped in a collection of two, a dozen, or even more 
individuals ; such groups being arranged in elongated, oval, pyram- 
idal, or ellipsoidal forms. Making its earliest appearance in the 
reticular portions of the corium, the growth may progress thence 
externally toward the papillary layer and epidermis, or downward 
to the subcutaneous tissue, or develop in both directions simulta- 
neously. Gradually there is invasion of the pilary and sebaceous 
follicles, the coil-glands being apparently less frequently involved. 
In the same way, the fat and vascular elements undergo a transfor- 
mation into the newly formed elements. The viscera are also 
changed by the pathological process, particularly the liver, kidneys, 
and spleen. By degeneration of these elements, atrophy, ulceration, 
and eventually the mutilating deformities of the advanced stages of 
the disease are induced. 



LEPRA. 659 

The results of the researches of Schmidt are in accord with the 
observations of Yirchow relative to the peculiar changes in the 
nerves. Explaining thus the hyperaesthetic, anaesthetic, and possibly 
also the pigmented alterations so characteristic of the malady, prolifer- 
ating elements are recognized by this author in the ependyma of the 
central canal of the spinal medulla, in the posterior commissure, and 
about the fourth ventricle. The nerve-fibres in the posterior and 
white columns, undergo degeneration, as also those of the medulla 
oblongata, the corpus striatum, and the Gasserian gauglion, the 
latter being in one case small, indurated, and its connective-tissue 
sheath thickened and adherent to the dura mater. The sheaths of 
the larger nervous trunks have been also seen to be involved, and the 
peri- and endoneurium atrophied as a result of previous infiltration ; 
the axis-cylinders often, however, persist. 

The relatively slow progress of the disease is explained by the 
exceedingly gradual development of the new-formed material ; its 
inaptitude, for long periods of time, to undergo retrogressive meta- 
morphosis ; and its tendency, for similar periods, to invade the skin 
exclusively, thus sparing for years the viscera whose ultimate involve- 
ment necessitates cachexia and a fatal issue. 

In leprosy, as in scrofuloderma and syphilis, the aggregation of 
the cellular elements in the new growth tends to form cutaneous and 
subcutaneous nodes. Similar nodules are found in cornea, cartilage, 
testicle, spleen, liver, bone, and other affected organs. The body of 
each cell sometimes grows till it has four and five times the dimen- 
sions it originally possessed ; being surrounded in its full maturity 
by an abundant vascular plexus. 

The specific parasite of leprosy, the bacillus leprae, is discovered 
in no other disease affecting man. It is visible within all cells 
actively concerned in leprous new 
formation. The bacilli are delicate FlG - 85> 

rods, with tapering extremities, 
one-half to three-fourths the di- 
ameter of a red blood-corpuscle, 

and have a breadth about one- c= ^=> * 

fourth of their length, as distin- /^/N S 

guished from the bacillus of ^-^fr- / 

tuberculosis. Granular parti- 
cles are occasionally recognized 
sprinkled through the proto- 
plasm of a single cell which 
iNeisser supposes to be either 
products of degeneration or spore 
formations. These various micro- 
organisms have been chiefly stud- ^/ 
iedjmd described by Hansen Bacilli of leprosy . flf epithelial scale . About 

(1870, 1874, 1880), Carter x 1200. (From one of the author's patients.) 

(1875), Neisser (1879), Cornil 

(1881) Hillairet and Gauche (1881), and in our country by Bermann, 

of Baltimore. These observers not only recognized parasitic organisms 





660 DISEASES OF THE SKIN. 

in various tissues of the bodies, living and dead, of the subjects of 
leprosy ; but have shown that the bacteria thus discovered were the 
causes of the disease. 

But one human being has been artificially inoculated with leprosy 
by the medium of culture-fluids originally derived from an infected 
person ; and the results are not wholly satisfactory. The appended 
illustration represents the bacillus leprae recognized in nodules taken 
from the arm of a patient affected with tubercular leprosy, exhibited 
at the author's clinic in 1886. 

These organisms have since been recognized in mucous membranes, 
perichondrium, cartilage, testicle, liver, spleen, kidney, lymphatic 
glands, and in the large cells between the peripheral nerve- fibres and 
fasciculi. Neisser has failed to recognize them in the spinal cord, 
muscles, pemphigoid lesions (bullae), and rete mucosum. The older 
and larger the cells, the more numerous and more closely packed are 
the rods of bacteria contained within them. 

Diagnosis, — In well-marked cases the recognition of leprosy is 
simple. In its prodromic periods, no suspicion of its existence would 
be awakened in countries where the disease is not endemic. 

From syphilis, which is also a disorder whose lesions are polymor- 
phic in character, lepra can be distinguished by its much greater 
chronicity ; its larger and brownish-yellow, glazed tubercles ; its 
frequent hyperaesthetic and anaesthetic symptoms ; its bullous lesions, 
rare in acquired syphilis ; the far more extended areas of its erythem- 
atous macules; its blackish crusts, lacking the rupioid aspect of 
those in syphilis; its leathery, mica-tinted cicatrices; and the charac- 
teristic leonine facies of its tubercular forms. 

Morpheea and vitiligo are both unattended by constitutional changes, 
and more particularly by no hyperaesthetic or anaesthetic symptoms in 
the affected patches. The atrophic and often deeply pigmented con- 
dition of the skin in the fiual stages of pityriasis rubra, associated 
with the emaciation and febrile condition of the patient, might mis- 
lead for a time the observer who had not a full history of the case. 
Multiple sarcomata, especially upon the face, are followed by much 
more rapid degeneration and a fatal result. 

All lesions of erythema multiforme can be readily distinguished 
from those of lepra by the absence of hyperaesthetic or anaesthetic 
symptoms. Syringomyelia is differentiated by its display of lesions 
only in regions where there is also muscular atrophy, by the 
much greater extent and lack of definition of areas of perturbed 
sensation, by diminution of the tendon-reflexes which may be ex- 
aggerated in lepra, by a marked predominance of symptoms in the 
upper as distinguished from the lower extremities, and by the fre- 
quent presence of scoliosis. The nodules of lupus are not symmetrical, 
are far softer, and are much more often grouped than those of lepra. 
Further, they never have the size of the larger leprous tubercles, and 
never have the peculiar pigmented, brownish, and oiled, or varnished 
aspect of leprous nodules. 

Finally, we are now in position to assert boldly that the diagnosis 



LEPRA. 661 

of leprosy requires not only clinical symptoms, but a definite conta- 
gion. Whether a history of transmission from one individual to 
another be or be not obtainable, it is certain that no person ever 
manifests leprous symptoms who has not been infected by some 
other individual who is a victim of the disease. 

Treatment. — One of the most important considerations relative to 
the therapy of leprosy is that requiring the segregation and isolation 
of all lepers from contact with the uninfected. In some countries, 
those particularly where leprosy prevails, wholesome laws enforce this 
separation of the infected, and charitably provide also for the care of 
the wretched victims of the disease. In this country, where leprosy, 
in consequence of its great rarity, has not yet awakened the attention 
of legislators beyond the point of forbidding the importation of 
infected persons, the proper care of lepers in a community only too 
ready to take alarm even at the name of the disease, is a serious 
matter. Many of our public hospitals for the care of the sick poor, 
refuse to receive lepers. The author has had experience in several 
States of the Northwest where the officers of health boards were 
powerless to make proper provision for the care of a leper whose case 
was brought to their attention. 

No remedies are known to have a directly curative effect in leprosy. 
As a consequence, the treatment of the disease is that suggested to 
the intelligent practitioner by the indications in each case. The most 
important of the latter is, when the patient happens to reside in a 
district where the disease prevails, an immediate change of residence 
and climate ; the adoption of a highly nutritious diet ; and the exhi- 
bition of roborant remedies, including steel, quinine, cod-liver oil, and 
often the moderate use of wines and malt liquors. The cinchonas 
and salicylates are indicated in morbid thermic conditions. Mercury, 
arsenic, the iodide compounds, Hoang-Nan in pills of three grains 
(0.266); creasote, in half-drop doses (0.033); the oil of cashew nut, 
gurjun balsam, chrysarobin, pyrogallol, resorcin, ten per cent, solutions 
of salicylic in oleic acid (Arning); ichthyol, and chaulmoogra oil, in- 
ternally and externally, have all been employed with varying success 
by different practitioners, but an unprejudiced review of the maxi- 
mum of results thus obtained will establish the conviction that no 
one of the remedies named may be regarded as in any sense possess- 
ing a controlling influence over the disease. Most of them have been 
employed by skilful physicians, sufficiently wise to enforce simulta- 
neously the most generous tonic regimen, thus clouding with some 
doubt a belief in the part played by the medicament in the produc- 
tion of the result. In the case of a leper and his little daughter in 
the State of Xebraska, who were treated by the author for some time 
with chaulmoogra oil, very marked benefit was noticeable in the 
course of a few months, a result he is quite willing to credit, in this 
instance, to the salubrious surroundings of a farm in the country. 

Every secreting ulcer and open surface in the person of a leper 
requires prompt and absolute disinfection with a solution of bichloride 
of mercury, in order to destroy the bacilli that are commonly present. 






662 DISEASES OF THE SKIN. 

Baths are of great value in all these eases, and may be medicated 
with any desirable substance. It should not be forgotten in the local 
treatment of leprous tubercles, ulcers, and other lesions, that however 
foreign the disease may be to this climate and this country, the simple 
principles, derma tological and surgical, by which one is governed in 
ordinary cases, are here not to be forgotton. Disinfectants, carbolic 
and boric acids, bland unguents, inunctions, and local stimulants of 
the skin, are as useful, when properly applied to the leprous, as to the 
syphilitic, the cancerous, and the scorbutic. 

Prognosis. — The future of the leper is indeed dark. The disease 
is malignant in character, and, however protracted, a fatal result is 
usually inevitable. Still, with a change of climate and improved 
hygienic conditions, much can be accomplished. There can be no 
question that the Scandinavian lepers who have removed to this 
country have been greatly benefited by the change. Such, indeed, 
was the opinion of the late eminent Professor JBoeck, who, during 
his useful career, visited Minnesota, and there studied the history of 
eighteen leprous immigrants who had come from his own country. 
He believed, in fact, that the change in some cases would work a 
complete arrest of the disease. A careful study of the history of 
leprosy in America will induce the belief that such a favorable result 
can be anticipated after residence in the Northwestern States, as well 
as in other portions of the country. 

The Sarttan Disease (Taschkent-geschwur) is an infectious 
granuloma, described by Heiman, and examined microscopically by 
Eudniew. 

It occurs in Taschkent, affecting the face, upper extremities, and 
trunk, avoiding always the palmar and plantar regions. Reddish 
macula? develop here into nodules, which desquamate, coalesce, de- 
generate, and leave crusted ulcers, which may cicatrize. 



Pellagra. 

Lat., pellis, the skin ; ceger, diseased. 

(Lombardy Erysipelas, Lombardy Leprosy, Kisipola Lombarda, 
La Rosa, Mai Roxo.) 

This disease has attracted attention by its extensive ravages in 
Lombardy and the contiguous provinces, including a portion of 
Southern France and Spain. It is a constitutional endemic disorder, 
accompanied by an exanthem, which justifies its brief consideration 
in this connection. 

The first symptoms of the disease, usually first noted in the spring, 
are prodromic, and characterized by marked fatigue, malaise, and 
occasionally by febrile symptoms. Soon the face, neck, chest, and 
backs of the hands and forearms (when exposed to the sun), are 
affected with an erythema of a dull, lurid hue, disappearing on pres- 



PELLAGKA. 663 

sure, which may be accompanied by desquamation, occurring in suc- 
cessive years chiefly in the summer season, often fading, at times 
with desquamation in the autumu. After frequent relapses, the skin 
becomes of a dark olive-brown, bluish-red, or deeply pigmented and 
bronzed hue, and general exfoliation of the epidermis follows in large 
flakes. Simultaneously, an extraordinary degree of muscular feeble- 
ness is noticed ; the skin becomes pruritic or hypersesthetic ; and a 
sensation of chilliness is induced, similar to that observed in general 
exfoliative dermatitis. As in that disease also, the fingers gradually 
become semi-flexed into the palm, and gastro-intestinal derangements 
supervene, accompanied by a furred tongue, inappetence, colicky 
pains, and diarrhoea. Disorders of the nervous system are betrayed 
by melancholia, disturbed vision, idiocy, convulsions, and symptoms 
of meningitis. Post-mortem, pachymeningitis, with induration, 
atrophy, and other secondary changes of the brain and cord, have 
been observed. 

The more one studies the cutaneous symptoms of pellagra, the 
more it is apparent that the erythema displayed is one corresponding 
in all points, save localization, to that of the other symptomatic ery- 
themata. Its colors are in different hues according to the age and 
sex of the patient and the stage of the disease. It disappears under 
pressure at first ; later it may persist even before the pigmented con- 
dition is produced ; it may be of congestive type and accompanied 
by bullous efflorescences and crusting with erosive features. It may 
subside in a fortnight not to return, or to return with successive 
seasons till the integument becomes gradually wrinkled, thinned, 
and in the xerodermatous state of impoverished senility. 

After the eruptive symptoms are inconspicuous, the important 
features are the muscular feebleness, the remarkable tendency to 
chills, alternating with febrile accesses, the flexion, more or less per- 
sistent, of the fingers into the palms, and in fatal cases, changes in 
the nervous centres such as pachymeningitis and sclerosis of nerve 
tissue, producing during the life of the patient, paralytic and paretic 
symptoms, melancholia, imbecility, and dementia. 

Pellagra has been very generally believed to originate in the use, 
as an article of diet, of maize which was either invaded by the fungus 
of ergot, or had developed other deleterious substances after its reduc- 
tion to a coarse powder. While this cannot be said to have been 
fully disproved, it is certain that individuals have suffered from the 
disease who have never partaken of maize, and also those who have 
not been specially exposed to the action of the sun, which in some 
cases seems to have served as the exciting cause of the disorder. The 
exact etiology of the malady should rather be traced by the statesman 
and politico-economist. The wretchedness, poverty, poor food, and 
hopeless moral and social condition of the inhabitants of the pella- 
grous districts, many of them toiling under a burning sun, half- 
starved, emaciated, and despairing, should explain largely the symp- 
toms of the scourge which afflicts them. Certainly there is here to 
be found a very satisfactory explanation of the failure of several 



664 DISEASES OF THE SKIN. 

writers on the subject to describe a disease of such typical aspect and 
career as to command recognition of its distinct aud special identity. 

Authors have indeed sought to distinguish between pellagra and 
pseudo-pellagra by establishing a difference of cause only, but this 
is futile. In cachectic men and women who have never been ex- 
posed to the sun and have not been known to be poisoned by eat- 
ing decomposed or fermented maize, all the symptoms of pellagra 
have been noted ; and in others mere exposure to the rays of the sun 
have in the cachectic and in those suffering from visceral disease 
(gastric carcinoma, disease of the supra-renal capsules, etc.), produced 
characteristic lesions of pellagra. 

The treatment is by prophylaxis ; improvement of the hygienic and 
climatic conditions of the patient ; quinine and the tonics in cases of 
debility; proper management of the nervous and gastric troubles; 
and, when practicable, a generous dietary. Lombroso recommends, 
as a prophylactic measure, care in the storing of the grain. 

The prognosis is favorable in some cases which are so mild as to 
be scarcely noticeable. In others, it is grave ; and in districts where 
the disease prevails extensively, the mortality has been frightful. 

Acrodynia (Epidemic Erythema) is an affection suggesting in 
its symptoms those of pellagra. It first occurred in Paris, in the 
year 1828, in an infirmary for aged men ; and has been since recog- 
nized in epidemic form in France, Belgium, Algiers, Mexico, and a 
few other countries. 

The disease begins with facial oedema, gastric distress, conjunctival 
injection, and hypersesthetic symptoms, with a sense of formication 
and pricking in the parts chiefly affected. The cutaneous lesions are 
erythematous, displayed in points over the extremities, and especially 
over the hands and the feet, particularly their palmar and plantar 
surfaces. It has either a simple or polymorphic expression, and is 
concluded by a furfuraceous or lamellated desquamation. 

When fluid-containing lesions are produced, these are either ves- 
icular or bullous, and filled with limpid or reddish contents. When 
the consequent exfoliation occurs over the palmar and plantar sur- 
faces, there may be a desquamation similar to that occurring in some 
of the exfoliating dermatoses, large horny flakes and casts being 
either firmly adherent to, or separable from, the tissues beneath. 

The grave complications of the cases are : oedema followed by atro- 
plry, paretic symptoms, febrile and gastric complications, and the 
supervention of senile marasmus. 

One of the most characteristic features of the disorder is the 
blackish hue of the skin of affected persons over the breasts, belly, 
flanks, chest, axillae, and inguinal regions. 

The pathology is obscure ; the treatment, that indicated by the 
general ill health of the patients ; and the prognosis, unfavorable. 



CARCINOMA. 665 

Carcinoma. 

Gr., napnivog, cancer. 

Carcinoma of the skin, is a term employed in the designation of the several 
forms of malignant tumors which are in part constituted of epithelial new- 
growth, either occurring primarily in the cutaneous tissues, or developing 
there after the involvement of other organs. 

The term Cancer has been both loosely and definitely employed in 
the designation of malignant cutaneous tumors. Every cancer of 
the skin is, according to some authors, necessarily both alveolar and 
epitheliomatous in structure ; while others distinctly recognize forms 
of cancer which are not epithelial. In these pages, for the sake of 
retaining a convenient clinical distinction, the term carcinoma, or 
cancer, is used generically to include epithelial, fibrous, and melanotic 
neoplasms. It will be understood, however, that in the structure of 
all of these new-formed groups epithelium plays an important part. 

Epithelioma. 

(Epithelial Cancer; Carcinoma Epitheliale ; Rodent Ulcer. 
Gee., Epithelialkrebs ; Fr., Cancro'ide.) 

Statistical frequency in America, 0.863. 

Three varieties of epithelioma are recognized — the superficial, the deep, and the 
papillary. 

Superficial, or Discoid, Epithelioma is usually first displayed 
upon the sound skin in the form of one or several, pin-head sized 
papules, flat infiltrations, disks, or nodosities of a dull-yellowish, 
reddish, grayish, or dirty wax-like hue. The growth may also have 
its origin in previously existing lesions of the skin, which are both 
numerous and different from each other. Among the latter may be 
named : fissures and excoriations (especially those long teased by 
caustic applications), warts, nsevi, acneiform and molluscoid lesions ; 
and the dry or greasy epidermal scales often seen at the orifices of 
the sebaceous glands in the faces of the aged. The outline of the 
newly developed growth as a consequence varies, being roundish, 
linear, or irregular. As a result of accident or traumatism (especially 
scratching and picking, which the history of a large proportion of 
all cases includes), a superficial excoriation forms, which may be 
covered with a sero-sanguineous crust, after the desiccation of its 
scanty and ichorous secretion. In the progress of its development, 
it is often noticed that new foci of disease appear in the immediate 
vicinity of the first, represented by sub-epidermic, indurated nodules, 
or superficial " pearls " resembling milia, whitish and lustrous, with 
marked tendency to vascularization, exfoliation, and superficial 
ulceration. 






666 DISEASES OF THE SKIN. 

The result is the ultimate formation of an ulcer, called also the 
Rodent Ulcer, Jacob's Ulcer, Ulcus Exedens, Noli me Tangere, 
Cancroid Ulcer, whose characteristics are marked. These are a 
roundish, fissured, or slightly angular contour ; and a reddish or 
reddish-brown, irregular, granulating, and mammillated floor, covered 
with a thin, translucent, viscid serum, which, in drying, suggests 
the effect of a varnish over the part. The edges of the ulcer are 
clean-cut, indurated, usually well attached; and, seen in horizontal 
profile, irregularly indented. The symptoms are slight at first ; the 
lymphatic ganglia and general health being unimpaired. Its site of 
election is the face, particularly the eyelids, nose, temples, and lips, 
though the genitalia, hands, and feet may be affected. Of two 
hundred and fifty cases collated by Heurtaux, in one hundred and 
ninety the face was attacked. 

Some English writers still describe the rodent ulcer as distinct 
from epithelioma, chiefly by reason of its individual peculiarities. 
Pathologically no distinction can be established between the two. The 
clinical features upon which this distinction is based are : the slow or 
intermittent development of rodent ulcer ; its tendency to destroy, as 
it extends, all the tissues within reach ; its failure to implicate the 
system by secondary deposits or metastases ; its rounded and often 
widely everted edges or, better, lip, often distinctly vascularized; its 
gouged floor exhibiting unequal levels ; its very slight tendency to 
granulation and its feeble or negative attempts at repair. All these 
are symptoms of epithelioma, if one chooses to employ that term 
in its large and proper sense. The rounded or oval excavation, often 
exceedingly clean-cut, at times with a corded and whitish rim, produc- 
ing, if any, little pain, is characteristic of the rodent ulcer, and yet 
in its extension it may exhibit all the symptoms of a deep epithe- 
lioma. 

Under the title " Crateriform Ulcer/' Hutchinson describes (Path. 
Soc. Trans., 1889, p. 275), a form of epithelioma distinguished 
chiefly by the rapidity of its invasion. Its onset is by the formation 
of a roundish or conical mass which rapidly exhibits ulceration, a 
central crater forming with exceedingly dense walls. 

The subsequent course of the lesion varies, its evolution being 
generally slow and accomplished in years. Sometimes having at- 
tained a maximum of size, the ulcer, if unmolested, long persists with- 
out appreciable change. In other cases, the base cicatrizes and the 
epithelioma completely exfoliates, leaving an outlying linear ulcera- 
tion which may persist or spread. In yet other cases, after a per- 
sistence of ten to twenty years, the ulcer may spontaneously close 
and the disease be at an end. Finally, any one of the destructive 
and malignant cancerous processes may be awakened, and the epi- 
thelioma be thus transformed from the type of the superficial to that 
of the deep variety of the disease. 

Deep, or Tubercular, Epithelioma. — This variety may origi- 
nate in the manner already described, or may be from the first 



CARCINOMA. 667 

characterized by its specific features. It commonly begins by the 
formation of roundish, very firm, pea-sized nodosities closely set 
together, in the skin and subcutaneous conuective tissue, or thus 
situated and well projected from the surface. In the course of 
months and years these develop to form a nut- or even small egg- 
sized tumor, roundish, dark reddish in color, and delicately vascular 
on its surface. This may be a deep nattish or globoid development 
within the skin ; or a well-defined tumor attached to it ; or (and this 
is a common form) a dense, thick, flattened plaque, one inch or more 
in diameter ; its walls steeply descending to the sound skin on either 
hand or moderately everted ; its centre depressed by atrophic changes; 
its surface shining, waxy, pinkish or red, with ramifying capillaries. 
" Satellites" may form in its vicinity. 

Degeneration of these forms produces in the course of time an 
ulcer either quite like that described above, or one which deeply and 
destructively encroaches upon the tissues beneath. In advanced cases, 
the latter is irregular in contour, with a clean-cut, everted, indurated 
lip; eroded and "gouged," haBmorrhagic and granulating floor; thin, 
viscid secretion which is foul and purulent at times when the result- 
ing destruction is rapidly accomplished ; and a deep attached base 
which may be perforated by a crateriform exulceration extending 
down to or through muscles, fasciae, cartilage, and bone. The 
lymphatic ganglia become simultaneously involved, and a general 
cachectic condition fully established. Death may ensue from maras- 
mus, exhaustion, or haemorrhage, in the course of several months or 
from one to three years. 

Papillary Epithelioma. — The cancer in this variety assumes 
the form of a malignant papilloma. In these cases, a pedunculated 
or sessile, narrow or broad-based, smooth-capped, or spongy and 
verrucous vegetation is attached to the skin upon which it forms. 
It may be originally as small as a pea, but usually increases consider- 
ably in volume, being not rarely pigeon's and turkey's egg-sized. 
The surface is either dry, reddish-yellow, smooth, and lustrous ; 
exfoliating, and secreting an offensively smelling sanguineous or 
translucent fluid ; or moist, granulating, filamentous, and intermingled 
with hairs, as when it occurs upon the bearded cheek. Degeneration 
occurs later, fissures forming first ; subsequently appear superficial, 
and finally deep, ulcers which ultimately assume all the features of 
the epitheliomata described above. 

Singular varieties of papillary epithelioma are occasionally seen 
upon the face. In a case lately observed by the author the entire 
face of an elderly man was covered with rings having a diameter of 
an inch or more, of which the centre was largely composed of densely 
indurated, cicatricial tissue. The borders of these rings were built- 
up of a reddish-brown, warty, cancerous growth, secretiug slightly, 
here and there commingled with the hairs of the face (beard, eye- 
lashes, brows), and elevated one- fourth of an inch and more above 
the general level of the integument. Growths of this sort are not 



668 



DISEASES OF THE SKIN 



rarely seen upon the back of the hand, over the forearm, and on the 
leg. Distinctly circinate forms are produced, the vegetation here 
having a dryish appearance, a brownish-red crust, neither bulky nor 
uniform, a cicatriform or infiltrated central area, and an exceedingly 
slow course. In some cases the epithelioma forms a soft, hemispheri- 
cal, small nut to egg-sized tumor, which, upon pressure discharges 
numerous convoluted plugs, composed of epithelium, fatty masses, 




Superficial papillary epithelioma of the face, with agglutination of ihe lobs of the ear to 
the cheek. The central portion of the right cheek is the seat of a cicatriform infiltration. 
{From a photograph of one of the author's patients.) 



and a purulent secretion. The bases of these soft masses are remark- 
able for the ease with which they can be curetted, and thus radically 
removed. 

A careful study ot well-marked cases of papillary epithelioma 
indicates clearly that while ulceration often results, the centre of the 
mass breaking down and furnishing a typical cancerous excavation, 



CARCINOMA. 669 

with hard and rouuded or oval border, uneven base, irregular granu- 
lating floor, aud offensive discharge, the picture is ofteu wholly 
different. Often the process extends widely over the brows, cheeks, 
and chin, wholly superficial, interspersed with raised cicatriform 
areas, suggesting that ineffectual attempts had been made to check 
the disease by surgical measures. These apparently atrophic disks, 
mingled with vascular, florid, fungiform, pyriform, and oddly shaped 
papillae, are really cancerous infiltrations of the type of discoid 
epithelioma. They may be seen gluing the lobe of the ear to the 
cheek, or everting the lower lid, even when superficial papillary 
vegetations are the predominant features of the disease. 

Epithelioma of the skin occurs also with multiform features, 
almost as numerous as the several different lesions from which a 
cutaneous cancer may take its origin. Thus a wart, a " button," a 
vegetation, a crack, an erosion, may, instead of healing, result in a 
fissure which bleeds easily and refuses to heal. After a persistence 
for months or years, an epithelioma forms assignable to one of the 
clinical varieties described above. In other cases, there may be a 
number of greasy scales upon the surface, resembling those seen in a 
well-marked seborrhoea sicca, and in one or two spots ; an attempt to 
remove these offers to the eye a superficial erosion implicating the 
derma, bleeding freely, and, when undisturbed, crusting and slowly 
spreading under the crust rather than healing. In yet other cases, a 
thin pellicle of apparently loosened epithelium, looking like a papery 
crust, is found, when removed, to cover three or more shallow ulcers, 
unexpected and hidden from view by the tenacious pellicle which 
had protected them and beneath which they had indolently and 
painlessly developed. 

These varieties, or types, of epithelioma may coexist in different 
portions of the same integument ; or the one may develop from the 
other a malignant papillary growth springing from a superficial or 
deep cancerous infiltration. Familiar examples of the disease are 
seen upon the lids and contiguous portions of the nose ; the cheek and 
the lower lid, the latter being often drawn into ectropion by a cicatri- 
form bridle or band ; the nose or lip and adjacent mucous or osseous 
tissue; and the glans and prepuce where the vegetating forms are of 
more frequent occurrence. The vast destruction wrought by the 
widest development and consequent degeneration of epithelioma is 
sufficiently recorded in the annals of both medicine and surgery. 
The author was lately consulted in the case of a woman sixty-four 
years of age, in the centre of whose face an ulcerating epithelioma had 
left a wide chasm, after destroying three-fourths of the nose and upper 
lip, and the hard palate with all the upper teeth and the antrum. 
The boues at the base of the skull were exposed. The case illustrated 
well the occasional remarkable tolerance by the system of the pro- 
foundest encroachments of epithelioma. She was then digesting and 
assimilating food with fair profit, and suffered chiefly from pain. 
She did not die till several mouths had elapsed, and then only as the 



670 DISEASES OF THE SKIN. 

result of hemorrhage from an ulcerative opening into one of the large 
arteries. 

Cancer of the Head. — In this region of the body nearly three- 
fourths of all cancers of the skin are recognized. Upon the brow, 
alse of the nose, temples, cheeks, chin, scalp, or other part, the 
disease may begin either upon or beneath entirely normal skin, or in 
that which has been pathologically changed. The origin of the 
disease is usually ascribed to the picking, scratching, or shaving of 
a sebaceous wart in the old man ; or in similar traumatisms of acnei- 
form, seborrhceic, or furuncular lesions in either sex. In other cases, 
the dermatologist, consulted with reference to some other ailment of 
the skin, can recognize, in persons of the age most liable to such 
accidents, one or several pin-head-sized, or larger milium-like 
nodules, clustered about the temples or nose, which indicate the site 
of the awakened epitheliomatous change. The disease progresses very 
slowly, spreading superficially, along the alse of the nose in irregular 
lines, in more complete centri frugal outliue over the temple and brow ; 
almost symmetrically over the tip of the nose, and with odd indenta- 
tions of contour in the dense integument immediately in front of the 
tragus of the ear. The vegetating forms are more common on the 
brow, scalp, and chin ; the " rodent ulcer " type, over the temples 
and cheeks. The more superficial varieties iu any part of the face 
may be slowly converted into the deeper. The flattened, egg-sized 
disks of infiltration are more common on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more 
conspicuous than in the face. Cartilage, bone, muscle, and entire 
organs melt before its ravages with astounding readiness. Within 
two years the author has seen a circumscribed flat epitheliomatous infil- 
tration, limited for years to one cheek, spread to the point of destroy- 
ing the ear, eye, and inferior maxilla of one side of the face, opening 
into the larynx and oesophagus, and not producing fatal results till 
the jugular vein of the same side had been opened by ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women, on account of the tobacco habits of the former, may arise 
either as a minute nodule, or circumscribed thickening on or near the 
vermilion border, usually of one side, or as a linear, narrow, and 
shallow excoriation, often protected by a thin crust, extending well 
along the mucous edge of the lower lip that is in contact with the 
other when the two are lightly approximated. Later, the lip may be 
the seat of a defined tumor, small-nut to egg- sized, which may deeply 
involve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla ; 
and eventually produce one of the formidable and remediless chasms 
of the lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon 
more frequeutly than to the dermatologist. The glans penis, clitoris, 



CARCINOMA. 671 

and prepuce are occasionally the seat of the warty variety ; but the 
scrotum, labia, thighs, mons veneris, and abdominal walls, as well as 
the parts first uamed, may be involved in the superficial or deep form 
of cancer. In persons of cleanly habits, the superficial variety of 
epithelioma may remain in this region as indolent and innocuous as 
upon the face. But where filth is permitted to accumulate about the 
part (lochial, menstrual, catarrhal secretions, pus, urine, feces, etc.) 
the spread may be relatively rapid. In such cases the ulcer is deep, 
seated upon an indurated and very tender base, and has the steep, 
punched edge and hemorrhagic floor of the rodent ulcer. Ulceration 
may, later, open the rectum, vagina, corpora cavernosa, perineum, 
and deep perineal fascia, resulting in vast destruction that proves 
fatal by exhaustion of the forces of the aged patient. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually of the papillomatous, or flat, superficial form. 
It may first appear upon the left hand of right-handed patients. Its 
progress is indolent, and when properly treated is much less liable to 
grave ulceration than epitheliomata in other situations. In special 
regions, especially on the lower extremity, where the force of gravity 
generally aggravates any ulcerative process, caries, necrosis, fistulse, 
loss of phalanges, etc., may result. 

Cancer of the Mucous Surfaces may be primary or second- 
ary in origin. The mucous lining of the oral and nasal cavities, 
vagina, rectum, and balano-preputial sac may be thus involved, 
either by extension of the disease from the neighboring cutaneous 
surface or by primary involvement of the mucous tissue. The most 
important, by reason of statistical frequency, is cancer of the tongue 
and buccal membrane, often having its origin in the leucoplasic 
striations, plaques, or thickenings, known as " smokers' patches," 
ichthyosis linguae, psoriasis linguae, etc. A pin-head to pea- or bean- 
sized superficial excoriation is usually the first lesion to which atten- 
tion is attracted, reddish in color, granulating, tender, and not often 
very painful ; or the beginning is a shallow fissure at the edge or on 
the tip of the tongue or on the mucous face of the lower lip, its long 
axis commonly at right angles to that of the organ upon which it 
forms. Beneath this with greater or less rapidity, as a rule slowly, 
a dense induration occurs, lancinating pains dart from the affected 
region toward the ear or along the jaw, the submaxillary and other 
glands become tumid and tender ; deglutition painful, and in severe 
cases well nigh impossible. Or, from the nasal membrane the disease 
extends toward the palate, pharynx, or larynx, ulceration when it 
occurs opening up a vast chasm which represents all these cavities. 
In the vagina and rectum a cancerous change may begin with merely 
a superficial thickening of the mucous membrane leading in the 
course of time to a superficial and later to a deeper ulcerative pro- 
cess ; or, as in cutaneous epithelioma, the papillary form may be 
represented in vegetations, cauliflower-shaped, filiform, or simply 



672 DISEASES OF THE SKIN. 

warty and mammillated, eventually degenerating, and furnishing the 
most formidable of destructive results. 

Paget's Disease of the Nipple and Areola (Eczematoid 
Epitheliomatosis of the Nipple ; Malignant Papillary Dermatitis ; 
Cutaneous Psorospermosis) was first described by Paget in the year 
1874, 1 and has since attracted the special attention of a number of 
English, French, aud American observers, including Thiu, Duhriug, 
Malassez, Darier, Wickham, and others. 

At the onset the disease suggests an eczematous involvement of 
the areola of the nipple, usually of one breast only, in women be- 
tween forty and sixty years of age. According to Besnier and 
Doyon, the earliest change is without any question a choking of the 
lacunae of the nipple with corneous cells, and this either without the 
operation of any known cause or as a consequence of a localized 
eczema, a galactorrhea, or other irritant. When early recognized the 
surface is intensely red and granulating, exuding quite copiously a 
clear viscid secretion, and producing subjective sensations of heat and 
burning, with intense or moderate itching. The definition is distinct, 
the tissue indurated, and the tenderness and pain usually well marked 
and distressing. In all the cases coming under my observation, a 
distinctive feature of the disease was the circumscribed infiltration 
of the skin and subcutaneous tissue which on palpation suggested a 
large-sized coin or button let into the substance of the areola and 
surrounding parts. 

When the disease has progressed to this point, a cancerous infiltra- 
tion of the breast is usually recognized, at least after its removal, 
though even with great care it may not be always possible to distin- 
guish it before ablation of the gland. Crocker, however, holds to 
the belief that the disease of the nipple may endure for years with- 
out resulting retraction and development of scirrhus of the breast. 
The French recognize three stages, that in which the disease is limited 
respectively to the nipple, areola, and breast, the latter of course suc- 
ceeding but not replacing the former. In all cases there is no attempt 
at repair , and when abandoned to its course the ultimate result, after 
five to eight or more years, is a profound ulceration with its destruc- 
tive effects most noticeable in the region of primary invasion, the 
entire breast having become cancerous. 

Pathology. — Darier and Wickham, in a series of interesting papers 
published during the years 1889 and 1890, attempted to show that 
this disorder was to be included in a list of morbid processes which 
they desired to include under their title of Psorospermosis, a group of 
affections of parasitic origin. These parasites were psorosperm-like 
bodies, coccidise in different stages of development, infiltrating the 
epidermis and all its prolongations. These coccidise, of the order of 
protozoa, multiplying by dehiscence and subsequent diffusion in the 
tissues, became centres about which the epithelial masses clustered. 

1 St. Bartholomew's Hospital Reports, p. 87, 1874. See also the paragraphs devoted to this, 
subject under the title of Eczema. 



CARCINOMA 673 

The coccidise were roundish or oval in shape, 0.03 in length, double 
contoured after section of their encompassing capsule. 

But later investigations have shown that the so-called psorosperrns 
are in fact simple alterations of epithelium which may be recognized 
in other affections as well as in Paget's disease of the nipple. Sec- 
tions of tissue in any case of well-marked malignant papillary 
dermatitis indicates with tolerable clearness the epitheliomatous 
character of the process. There is a definite limit between the 
healthy and morbid tissue ; the rete pegs extended downward, fix 
their claw-like prolongations into the deeper structures ; there is 
lymphoid cell infiltration ; epithelial nests ; perivascular infiltration, 
squeezing, and in portions obliteration of papillae ; loss of the super- 
ficial epiderm, when ulceration or erosion occurs ; and, as pointed out 
above, choking of the lactiferous ducts with corneous cells. It is in 
fact by these ducts that the malignant process extends from nipple 
to gland ; and this renders it in all cases a matter of extreme doubt 
whether the process is actually limited to the nipple and areola, or, 
when this choking has occurred, whether the gland is not already 
secondarily invaded. 

Diagnosis. — There are a few cases where the raw and exuding 
surface can be mistaken for an eczema. The latter, when occuring 
upon the surface of the breast and of the nipple, is far more com- 
mon during earlier periods of womanhood than after the fortieth 
year, chiefly among those giving the breast to sucklings. Eczema is 
never, under any circumstances, capable of producing in this region 
the characteristic button- or coin-sized induration beneath the deep 
red raw granulating surface of the cancerous infiltration. 

The Treatment of Paget's disease should always have in view the 
possibility of cancerous involvement of the gland which usually 
occurs, though a number of cases are on record when relief by other 
than radical measures was secured. Caustics should never be em 
ployed ; all irritants are to be avoided. Soothing applications, as in 
corresponding states of eczema, the pastes, zinc aud calamine lotions, 
diachylon and other soothing salves, are indicated and often prove 
serviceable. The employment of parasiticides, now that the psoro- 
spermosis theory of the disease is " menaced with death," as Brocq 
declares, will hardly meet with favor. Weak mercurial lotions fol- 
lowed by powders of aristol, or hydronaphthol (one part to one 
hundred), aud weak ointments of pyrogallol or iodoform are also 
extolled. In one of my patients complete erasion of the morbid 
tissue was successful. 

The Prognosis is not always grave. Cases are reported as relieved 
by local measures, which are always worth a judicious trial, but it 
must always be borne in mind that ineffectual measures may permit 
the involvement of the breast, eventually calling for ablation of the 
entire gland. 

Etiology of Epithelioma. — The essential causes of cancer are un- 
known, though there can be no question that mechanical, chemical, 

43 



674 



DISEASES OF THE SKIN, 



and other local irritations are often the immediate excitants of its patho- 
logical processes in the predisposed skin. In this way the excoriations, 
warts, nsevi, and other lesions named above, though not in themselves 
cancerous, may become the original sites of the disease. In this way, 
too, the irritation produced upon the lip of the smoker by his pipe or 
tobacco ; the local disorder about the iuner canthus of the eye resulting 
from occlusion of the lachrymal ducts ; the frequent teasing by caustic 
or other substances, of the wart on an old man's hand ; and other 
agencies disturbing the balance between waste and repair, aided at 
times by senile atrophic changes, may result in the development of 
an epithelioma. The possibility of the transmission of cancer by 
heredity has almost ceased to obtain credence in the light of modern 
pathology, yet Broca reports sixteen deaths from cancer in one family, 
and Friederich, a congenital epithelioma in the child of a cancerous 
woman. 



Fig. 87. 




Epithelioma, vertical section, a, d, cones of the rete projecting downward ; between these 
are seen atrophied papillae, b ; at e, d, and other points, are " nests " of epithelium ; c, atrophied 
stratum corneum. (After Kaposi.) 

The disease is eminently one of advanced years, being most fre- 
quent after the fortieth year, and a pathological curiosity in child- 
hood. Kaposi reports one case at the tenth year. Only about thirty 
per cent, of all cases occur in women, a fact possibly explained by 
the relative infrequency of the action of local irritants in those who 
are not subjected to the exposure incidental to the trades and severe 
occupations of life. 

These figures, however, relate only to cancer of the skin, since, 
when cases of cancer of the breast and uterus are included, the pro- 
portion of the sexes affected is almost exactly reversed. 

In favor of the local origin of cutaneous epithelioma is the clinical 
fact of the excellent general health of most patients in the earliest 
stage of the malady ; while those affected with syphilis and tuber- 
culosis are usually exempt. 

Pathology. — The histological forms of epithelioma are well classified 
by Vidal, 1 as follows : 1. The interpapillary form, in which cylin- 



i Gazette des HGpitaux, Nos. 113 and 114, 1879. 



CARCINOMA. 675 

drical or peg-like epidermal prolongations flattened at the periphery, 
penetrate downward from the rete, often in parallel columns, between 
the papilla? of the corium, and are occasionally connected below by 
a species of anastomosis. Here, at times, onion-like " globes/' 
" nests," or clusters of concentrically arranged epithelial masses are 
to be recognized, the centre, as Heitzmann remarks, being often 
occupied by epithelium in a state of fatty degeneration. In this 
way the derma and subcutaneous tissue may be, after previous vascu- 
larization, completely invaded. 2. The lobulate form, in wdiich the 
epidermic globes are in pronounced excess, forming distinctly defined 
masses invading the connective tissue. Here multiplication of the 
elements is abundant, thus diminishing or occluding the lumen of 
the vascular elements, and leading to necrobiosis and ulceration. 3. 
The tubular form, cylindroma of Billroth, the adenome sudoripare, 
of Verneuil. In this, tubes like sweat ducts with a calibre, penetrate 
the meshes of the connective tissue, often intermingled with epidermic 
globes. It is largely this form of the disease which Tilbury Fox 
and T. Colcott Fox 1 have recognized as originating from the external 
root sheath of the hairs. 4. The pearly form, which Heitzmann has 
demonstrated to result from fatty degeneration of the epithelium in 
the centre of a " globe" or "nest." 

With regard to the secondary structural metamorphoses of epithe- 
lioma, these are due to fatty degeneration of the epithelium, which 
process may result in its calcification. Waxy degeneration of both 
epithelium and connective tissue produces the appearance of shining 
homogeneous masses within the tumor, which are characterized by a 
noteworthy indifference to the action of chemical reagents. Colloid 
and adenoid metamorphoses follow the breaking apart of already 
formed cancer epithelium, into medullary elements from which myxo- 
matous tissue arises. Cystic cancer is a higher development of the 
colloid form, where the myxomatous tissue in the alveoli liquefies. 
The papillary forms are exuberant growths of circumscribed portions 
of the tumor toward and beyond the surface. 

Briefly, every column, " nest," " globe," or tubular prolongation 
within the skin, containing within itself an irregular admixture of 
epithelium and connective tissue, is a cancer, or epithelioma, whose 
gravity seems to be proportioned to the relative development of the 
contained epithelium. The origin of the latter is to be sought in 
connective tissue. The medullary elements into which connective 
tissue is transformed as the result of an inflammatory infiltration, 
have been traced in the process of metamorphosis into cancer epithe- 
lium. Once fully developed, the neighboring lymphatics are invaded, 
and secondary involvement of the viscera may follow. Minute epi- 
thelial particles of the neoplasm are swept into the lymph ganglia, 
thence through the lymph to the bloodvessels ; where finally, lodged 
in capillaries with a narrow lumen, they produce embolism. 

The malignant forms of cancer may undergo changes by which 

1 Trans, of the London Path. Soc, 1879. 



676 DISEASES OF THE SKIN. 

they are transformed into sarcoma. In these, the epithelia become 
gradually indistinguishable as such, in consequence of a species of 
liquefaction by which they are converted into medullary elements. 

Geber explains the pathological changes as follows : 1 . Enlargement 
of cones of the rete, the peripheral epithelium becoming cylindrical ; 
the central showing cubic and rhombic, or flat, compressed, polyg- 
onal, dentated, and spinous elements. There are multiple nuclei, 
nucleoli, and vacuoles. 2. The sprouts of epithelium passing into 
the connective tissue become so long, flat, and abundant that the 
products of secondary inflammation choke them at one point or 
another, so that separation occurs, and the isolated part becomes a 
brood-nest for one or several cancer colonies. 3. The cylindrical form 
of the cells is either then not visible or rudimentary in character, 
the cells and nuclei dividing. 4. There is dichotomous division of 
the smaller and infiltrated papillae, projected beyond the general 
surface of the skin, producing thus the papillary form of cancer. 
Or, the irritation progressing pari passu with the proliferation of 
epithelium, the corium is uniformly infiltrated with round cells, the 
connective tissue corpuscles multiply, the vessels dilate, and the cells, 
constituting their parietes, proceed to further development. 

When the epithelioma originates in the deeper strata of the 
corium, a round-celled proliferation affects all the epithelial structures 
in the cutaneous glands and hair follicles, as well as in the deeper 
portions of the rete mucosum. The epithelial cones are large, and 
increase out of proportion to the stroma of the cancer-tumor, which 
is, therefore, softer and more juicy. The bloodvessels and lymphatics 
multiply, especially in the rapidly growing nodules. As the disease 
advances, nervous, muscular, cartilaginous, osseous, and other tissues 
may undergo a cancerous transformation, or be simply eroded before 
the inflammatory and pressure effects of the growing neoplasm. 
Occasional terminations of the disease are by exfoliation, ossification, 
calcification, fatty metamorphosis, and sloughing en masse. 

Diagnosis. — Epithelioma is to be distinguished from lupus vulgaris 
approximately, by the age of the patient, the latter disease rarely 
appearing after the thirty-fifth year where there is not a scar or 
history of its earlier existence. Lupus is, at an earlier period of its 
career, more diffuse than epithelioma ; its elementary lesions are 
more distinctly groups of individuals than a homogeneous aggrega- 
tion ; its ulcers are more often bordered by outlying non- ulcerative 
papules, furnish a more puriform discharge, and, most distinctive of 
all, are never walled about by the firm, densely indurated, often 
everted lip of the epitheliomatous ulcer, opening out often to a sound 
peripheral integument. The peculiar and often characteristic odor 
of the cancer discharge is absent in lupus. 

From syphilis, epithelioma is to be distinguished : first, by the 
age of the patient, syphilis being decidedly a disease of early and 
middle life ; second, by the far greater relative rapidity of the syphi- 
litic process, exception being always made of tertiary gummatous 
ulcers upon the lower extremities persisting for years when there is 



CARCINOMA. 677 

both lack of internal treatment and local support ; third, by the 
history of the disease in each particular case ; and fourth, by the 
characteristic syphilitic features always preseut in infected individuals, 
including multiplicity of lesions, typical cicatrices, contour of ulcers 
(that of epithelioma is less often either reniform, horseshoe shaped, 
or crescentic), character of discharge, and general absence of pain. A 
very important point to note is a marked tendency to reparative 
cicatrization in old syphilitic ulcers, partly due to the exhaustion of 
the infective poison, partly to the influence of the insufficient but yet 
modifying treatment so common in this country. This is exceedingly 
rare in epithelioma, the latter being often, the former rarely, a 
malignant disease. 

Epithelioma of the genitals is not to be confounded with chancre, 
gumma, or syphilitic tubercles of that region. The peculiarities of 
the consequent adenopathy in each case ; the lancinating pains of the 
cancer ; its much more prolonged duration ; and occurrence in an 
aged subject, with the general history of the case, will usually point 
to the truth. 

Sarcoma is characterized by : its far more rapid evolution, tumors 
often attaining their maximum of development in the course of a few 
months ; its occurrence by predilection in earlier life ; its inaptitude 
for ulcerative degeneration ; and its marked tendency to multiplication 
in contiguous or distant portions of the body. 

The warts, naevi, excoriations, and seborrheic lesions, from which 
epitheliomata often take their origin, cannot be determined as having 
such a tendency before the cancer has attained some development. 
Every such persistent and long irritated lesion on the person of a 
male subject of advanced years, should be regarded with a degree of 
suspicion. 

Treatment. — Xo internal treatment of cancer of the skin is known 
to exert the slightest influence upon the growth. 

The topical treatment of epithelioma is by excision, erasion, or 
destruction of the growth. The first is performed by surgical abla- 
tion with the bistoury, after which one of the plastic operations may 
be required for either the complete covering of the w^ound, or the 
relief of the resulting deformity. The second is applicable only to 
the less formidable growths, and is performed by the aid of the dermal 
curette. The third is effected by the use of caustics. 

Destruction of smaller cancerous tumors of the skin may be per- 
formed by the aid of caustics, of which caustic potash, in stick or 
solution, is, perhaps, the most valuable, as its destructive action may 
be controlled by the topical employment of acids, and is followed by 
less pain than some other chemical agents. Other caustic substances 
employed for a similar purpose are : chloride of zinc, Vienna paste, 
nitrate of silver, arsenical paste, resorcin, pyoktanin, fuchsine, and 
pyrogallol. The latter is recommended highly by Kaposi, not only 
because its application is unproductive of pain, but also because it 
does not attack sound tissue. It is used in an ointment of ten per cent, 
strength. All such pastes and ointments should be spread upon cloths, 



678 DISEASES OF THE SKIN. 

and applied for from three to six days. Opiates may be required, 

in the case of several of these agents, to relieve the cousequent pain. 

Among the formulae used for caustic purposes are the following : 

Be. Creasoti ^ss; 16 

Acid, arsenios. gr. iv ; 266 

Opiipulv. gr. ij; 133 M. 

Sig. For employment upon circumscribed surfaces. [Kaposi ] 

Marsden's paste, also employed as a caustic, is made by combining 
equal parts of gum Arabic and arseuious acid with water sufficient to 
make a softish paste. It is preferred by Robinson x to others, and is 
applied on rubber plaster. 

Cosme's paste, as modified by Hebra, is prepared as follows : 

40 



R. Acid, arsenios. gr. vj ; 

Hydrarg. sulphuret. rub. g ss ; 2 

Unguent, aq. ros. ^ ss > 16 
Sig. Arsenical paste. 



M. 



The method of its application is as follows : The paste is spread 
over a thiu sheet of lint to the thickness of a knife-blade, and the 
lint then cut to a shape aud size corresponding with that of the tumor 
or ulcer to be destroyed. After its close apposition with the surface 
to be attacked, it should be covered with gutta-percha, or other 
impermeable tissue, and a compress laid over the whole. The dress- 
ing is removed, the parts washed clean, and the same application 
renewed in twenty-four hours. By the third or fourth day, the 
destruction of the cancerous growth is usually complete, and the 
parts are ready for an emollient poultice, which should be applied 
for the three or four days during which the separation of the 
sloughs occurs. The simple ulcer left is to be treated on general 
principles. The danger of arsenical poisoning is here reduced to a 
minimum ; the treatment being very effectual where patients consent 
to the delay as to time and to the very severe pain which it occasions. 
It has been used by me with satisfactory results, and is highly 
praised by Atkinson 2 in an admirable lecture on epithelioma, deliv- 
ered by him in the University of Maryland. 

The thermo- and gal vano- cautery may also be often advantageously 
used for the destruction of the growths. I have used the former by 
preference in many cases, occasionally without, often with, return of 
the neoplasm. Its advantages are : the transitory character of the 
induced pain ; the coal-like dressing left upon the attacked surface ; 
and the elegance of the resulting scar. Both measures find their 
highest value when employed after effectual incision or erasion. 

Whatever method be employed, thoroughness is essential in attack- 
ing all portions of the new growth ; and it is well to encroach some- 
what upon the unaffected contiguous structure. The subsequent 
dressings should be made with simple or carbolated unguents, to 

1 Some Considerations on the Treatment of Cutaneous Malignant Epitheliomata. Internat. 
Journ. of Surg., 1892. [A valuable paper.] 

2 Reprint, in Chicago Med. Journ. and Exam., Aug., 1883, p. 188, from the Virginia 
Medical Monthly. 



CARCINOMA. 679 

which one of the salts of morphia may be added in case of continuous 
pain. The eschar usually separates in the course of a few days, 
leaving a simple granulating wound which may cicatrize soundly, 
and the epithelioma be thus radically relieved. In other cases, the 
disease reappears in the ulcer or cicatrix ; or by recurrence of can- 
cerous nodules in the previously sound integument. Even after 
these recurrences, prompt destruction of the new growth may be 
finally successful. 

But little confidence is placed upon any external treatment which 
does not effect the complete destruction of the neoplasm. Yet there 
are those who highly esteem some of the procedures which are less 
radical in their aim. It is proper to mention these. 

There can be no doubt whatever that some circumscribed and 
relatively small growths disappear under the borated hot-water treat- 
ment. The sole question which then arises, concerns the possibility 
of spontaneous recovery in such cases irrespective of the treatment 
pursued, since such spontaneous involution is a clinical fact, rare of 
occurrence though it may be. By this method, the neoplasm is 
sponged with hot borated water for from fifteen to twenty minutes 
every three hours of the day, and oftener if possible, for three weeks 
in succession. The water is as hot as can be tolerated, and applied 
by the aid of a bit of sponge mounted on a probang. During the 
course of the application, water in a state of ebullition, is added in 
small quantities to that in which the sponge is dipped from minute 
to minute, thus keeping the temperature at the highest tolerated 
point. Immediately after each application, the part is thoroughly 
dried, and then either anointed with a bland unguent or completely 
covered with boric acid, aristol, europhen, or iodoform in powder. 
When such applications are of service, the good effect will usually be 
noted in a week. The ulcer changes its aspect in color, edges, and 
floor ; and the pain, if any have existed, is greatly relieved. Granu- 
lations of a healthy type appear, and the lips of the sore contract. 
Non-ulcerated lesions shrink in volume, and otherwise change in 
feature. This system of " parboiling " has the advantage of not pre- 
cluding the ultimate employment of radical measures. The largest 
epithelioma completely relieved by this method was of the type of 
the u rodent ulcer/' on the temple of a male patient seventy-two 
years of age. It had the size of a section of a small hen's egg. The 
resulting cicatrization was satisfactory in all respects. There has 
been no return in two years. Needless to say, the method will often fail. 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large 
success in the treatment of epithelioma by chlorate of potash. 
Locally, the part is frequently touched with a saturated solution of 
the salt in glycerin and warm water, after which a simple ointment 
dressing is applied. Vidal administers also the same drug inter- 
nally, in doses of a drachm and a half (6.) in syrup and water before 

1 Glasgow Medical Journal, 1881. 2 Loc. cit. 

3 Acad, de Med., Paris, 1873. 4 These de Paris, 1877. 



680 DISEASES OF THE SKIN. 

meals. It is possible that any remedial effect obtained from such 
measures should be attributed to the fomentations employed. 

Latterly, benzole has been reported as a valuable topical applica- 
tion to small-sized epitheliomata. The author has employed it in 
several cases with no very marked results. 

Injections of solutions containing copper-sulphate, iodine, alcohol, 
acetic acid, nitrate of silver, chloride of sodium, and hydrochloric acid 
have been practised, it is claimed, with some success ; certainly at 
times with fatal results. The method is unquestionably inferior to 
others described above. 

Prognosis. — In general, the prognosis of cutaneous cancer is grave. 
The relative degree of gravity will, of course be largely proportioned 
to the variety, form, size, career, and complications of the growth in 
each case. The variety in which only " pearls " form in the skin is 
the most benign of all, as the lesions are usually isolated, and may, 
when unirritated, undergo spontaneous exfoliation. In other cases, 
the disorder for from fifteen to twenty years seems to make no pro- 
gress of any sort. The malignity of a cancerous growth is always 
proportioned to the quantity of epithelium contained in its alveoli as 
compared with the connective tissue present ; the more abundant the 
latter, the more favorable the prognosis. Naturally, also, the deeper 
and the more destructive the growth, the fewer are the chances of 
ultimate recovery. Excessive pain and adenopathy are unfavorable 
symptoms in any case. Koch 1 gives some interesting statistics of the 
results of operations, at the Erlangen Clinic, for the removal of 
epithelioma of the lower lip, in one hundred and thirty-one patients 
exhibiting primary lesions. One hundred and fifteen were for the 
time " cured " ; four had speedy relapse ; and three were, at the date 
of writing, living and suffering from recurrence of the disease. The 
prognosis was thus absolutely favorable in but twenty-eight cases. 

Cancer of the Connective Tissue. 

This is rare as a primary cutaneous manifestation, but appears 
generally as secondary to a cancerous involvement of other organs, as 
of the female breast. It is termed also Scirrhous, Hard, Fibrous, 
or Lenticular Cancer. It occurs either upon the skin covering 
a breast which has been previously transformed into a cancerous 
mass, or as a cutaneous relapsing lesion after the extirpation of the 
latter. Its symptoms are pea- to bean- sized, densely firm, shining 
nodules, varying in color ; or a more or less diffuse infiltration of the 
skin of similar characteristic hardness, associated often with hyper- 
emia of a purplish-red shade. 

Cancer en Cuirasse. — An interesting case of widely dissem- 
inated leuticular cancer of the skin, illustrated by an excellent 
portrait, is described by Dr. P. A. Morrow, 2 occurring in a healthy- 

! Centralblatt f. Chirurg., 1881, No. 40. 

2 Journal of Cutan. and Vener. Diseases, June, 1F84, p. 1. 



CARCINOMA. 



681 



looking woman as a secondary phenomenon after removal of primary 
cancer of the breast. 

I have had several cases of this disorder under observation, two 
made the subject of a paper, with illustrations of the clinical appear- 
ances and morbid condition of the tissue. (American Journal of the 
Medical Sciences, March, 1892.) Whether the nodules be, as to cuta- 
neous manifestations, primary or secondary, the symptoms are gen- 
erally the same. The lesions are closely set, shining, firm, reddish 
papules, infiltrations of a dull reddish hue, miliary and pigmented 
deposits, tubercles varying in size, subcutaneous nodules, and sec- 
ondary results in the way of formidable ulcers, crusts, and fungous 
growths. 

Fig. 83. 




Cancer en cuirasse, chiefly involving the right side of the chest. (From a painting in oil 
of one of the author's patients.) 



When the cancerous infiltration is widely diffused and densely 
indurated, involving a large portion of the integument of the thorax, 
the condition is termed by the French cancer en cuirasse, a title first 
given by Velpeau. In these cases the condition is striking in its 
peculiarities, and in the highest degree serious. The integument of a 
large portion of the chest, usually more in front, but also behind, and 
even a part of the anterior abdominal wall, is converted into a dense 
leathery envelope, often compressing the chest walls so as to seriously 
impede respiration. The edges of the infiltration are poorly defined 
save at the lines where tongue-like prolongations (languettes) of dull 
reddish hue indicate the advance of the scirrhous process over the skin. 



682 DISEASES OF THE SKIN. 

» 

The lymphatic circulation is obstructed; the glands enlarge; and, what 
is almost pathognomonic of the disorder, the upper extremity, usually of 
the side chiefly involved, becomes enormously swollen and cedematous. 
The nipple may be or not retracted ; the breasts, one or both, are firmly 
bound down to the chest wall by the cuirass of dense skin, hard, 
smooth, or rough, shining, and either reddened in dull hues or of nor- 
mal tint, here and there traversed by vessels, and breaking down into 
ulcerations, usually first about the nipple, but also elsewhere. The 
process is one of the more rapid of the scirrhous metamorphoses of 
the body, as a fatal result is usually reached in a few months, though 
years have in some cases elapsed before death has resulted. One of 
my patients, an unmarried woman, with breasts in the virgin state, 
perished in the course of a few months, the cancer having originated 
in the skin. The milium-like masses, as large as grains of wheat, 
conspicuously present in Morrow's case, undergoing fatty degenera- 
tion in the centre and readily expressed like comedones, were incon- 
spicuous features of all my cases. The prognosis is of the most 
serious. 

Pathologically, the several forms of carcinoma here described are 
epitheliomatous, since the fibrous stroma always contains, in the 
centre of narrow alveoli, a relatively small number of epithelial 
bodies. The growth is usually slow of development, but in the end 
accompanied, as are other cancerous tumors, by adenopathy, pain, 
and ulcerative changes, which induce an inevitable cachexia. As 
with the other varieties, relapse after extirpation is common, and the 
prognosis is proportionately grave. 

Tuberose Carcinoma 

is a rare manifestation of the disease, occurring in the form of mul- 
tiple, firm, peanut- or egg-sized, roundish nodules, which break down 
by ulcerative processes into deep losses of tissue. It is frequently 
accompanied or followed by cancerous involvement of other organs. 
It occurs chiefly upon the face, hands, arms, and chest, though also 
upon other portions of the skin of persons of advanced years, either 
as a primary or secondary cancerous manifestation. Guinard 1 reports 
the case of a cancer of this variety, remarkable for the small size of 
the existing nodules, which varied from that of a hempseed to a pea. 
They covered the entire thorax, back, and right arm, and had here 
and there broken dow T n into ulcers. One of the latter was as large as 
the hand. 

Melanotic, or Pigmented, Carcinoma 

is that form in which both the epithelium and connective-tissue 
framework of the cancer are richly supplied with bloodvessels, and, 
probably, as a consequence of transudations from the latter, an abun- 

i Union Med., February 5, 1981. 



CARCINOMA. 683 

dant supply of pigment granules in groups and clusters. These 
growths usually begin as hempseed- to pea-sized, single or numerous, 
soft or dense nodules, which may develop in time to tumors of con- 
siderable size, and are stained in various shades from a grayish-brown 
or a slate-color to a dead black, the pigment being occasionally dis- 
played irregularly in streaks or bands over the surface of the growth. 
They occur over any portion of the surface, often upon the extrem- 
ities and genitals, starting frequently from benign pigmentary lesions, 
such as nsevi and moles. Anatomically, the pigment is found to be 
deposited both between the cells and in the protoplasm of the cells 
themselves. 

The author has, in a few instances, seen the disease limited to single 
melanotic growths of this character. The cancer is apt to develop in 
the papillary form, furnishing thus fungoid vegetations which have a 
noteworthy tendency to degenerate into ulcers. Often such verruc- 
ous masses are seen surrounded by grayish or blackish papules, or by 
a diffuse cancerous infiltration of the integument, exhibiting irregular 
pigmentation of the surface. The disease is apt to appear in the 
viscera, in the form of disseminated cancerous nodules, each highly 
vascular, and exhibiting in varying quantity granules of pigment. 
The growth has usually a relatively rapid course and malignant 
career. Relapses are frequent, the amount of pigment usually 
increasing with each relapse. A nut-sized melanotic cancer of the 
skin, removed from the hand of a patient in Chicago by one of the 
author's colleagues, was not followed by other manifestations of the 
disease during the ensuing year. At the end of that time the patient 
passed from observation. 

Benign Cystic Epithelioma. (Hydradenome Eruptif, Cellu- 
lome Epithelial Eruptif.) — Jacquet, Darier, and Quinquaud have de- 
scribed under these titles a dermatosis occurring upon the neck, 
chest, and upper extremities, chiefly characterized by its indolent 
course and by the evolution of shot-like, reddish or rosy-reddish 
papules, somewhat firm and seated within the derma. They vary in 
size from a pin-head to a pea ; and are oval in contour, their long 
axis usually directed in the line of the cutaneous folds. 

The observers named believe these to be benign epitheliomata 
developing as a result of the evolution of aberrant embryonal epithe- 
lium, originating often in the coil-glands. 

Leucokeratosis Buccalis. 

(Leucoplasia ; Psoriasis Lingua? ; Smokers' Patches of the Mouth ; 
Buccal Psoriasis ; Ichthyosis Linguae ; Leucoplakia Buccalis.) 

In the year 1868, Bazin described with tolerable accuracy the 
several conditions indicated by the names given above ; and since 
that date the subject has been enriched by a literature contributed by 
Debove, Kaposi, Sigmund, Plumbe, Mauriac, Schwimmer, and others, 



684 DISEASES OF THE SKIN. 

including my colleague, Prof. E. Fletcher Ingals, who has seen sev- 
eral of my patients and who has kindly permitted me to examine 
his. I have selected for the title of these paragraphs that given by 
Besnier and Doyon, as the least misleading and the most descriptive. 

The disease is manifested chiefly in the mouth, by the occurrence 
on the inner faces of the lips and cheeks, and on the dorsum and 
edges of the tongue, of dull-whitish, slate- colored, or silver- whitish 
points, disks, streaks, bands, ribbons, or patches of an irregular 
shape, either flattened, or slightly elevated above the general level 
of the mucous surface. The disease may occur in isolated points 
or in pin-head sized nodules, discrete or confluent, and in cases 
grouped, the grouping being often in linear arrangements, following 
the lines indicated by the streaks or the striae of similar composition. 

The sites of election of these lesions are : the inner face of the cheek 
in a line following that traced by the conjunction of the teeth of the 
upper and lower jaw when approximated ; the gums above the 
upper canine teeth and lateral incisors ; the sulcus beside the upper 
and lower gums in the roof and floor of the mouth ; the dorsum and 
edges of the tongue, where the arrangement is usually in lines along 
the longitudinal axis ; and more rarely other parts. 

When closely examined, these lesions are found to be made up of 
a hyperkeratinized epithelium, being covered by an adherent and 
more or less dense pellicle, removable only by artificial measures and 
closely applied to the inferior stratum of the mucosa. The lesions 
are rough to the touch, both of the finger of the physician and to the 
tongue of the subject of the disease, but are, as a rule, not painful, 
though at times annoying by producing a certain degree of stiffness 
and immobility of the parts affected. At times the membrane in the 
vicinity is reddened and tender. 

These lesions are extremely chronic of evolution, requiring months 
and often years for their full development, and resisting in a remark- 
able way the action of topical medicaments. They may be removed 
without recurrence ; or may recur after complete and radical ablation. 
If unmolested and not undergoing resolution (a termination some- 
what doubtful of occurrence), they usually, by reason of increased 
density, crack or fissure at one or another point, the fissure extend- 
ing to the derma and arousing a local inflammatory process with the 
production of pain and distress. The surface is then apt to exfoliate 
and ulcerate ; beneath these, sclerotic tissue is formed, and epithelioma 
of the mouth may result. 

The proportion of the benign cases to those which result in epithe- 
lioma is not determined. Every leucokeratosis, however, may prove 
the initial stage of an epithelioma of the mouth ; and the treatment of 
the former is therefore a matter of no little consequence. 

The Etiology of these cases is suggested by some of the names given 
above. Unquestionably the irritation produced by tobacco, whether 
used by smoking or chewing, and the influence of carious teeth or 
those with sharp edges after fracture, irritating the edge of the tongue, 
are all important. The resemblance of these lesions to both the 



CARCINOMA. 685 

mucous patches and scaly patches of syphilis is obvious ; aud it is 
believed that syphilis, when not actively efficient in the production 
of leucokeratosis buccalis, may be one of its indirect causes. It is, 
however, very important to note that all the symptoms here described 
occur in persons who have never suffered from syphilis ; and such 
symptoms are in the latter class fully as intractable as in others. 

The Pathology of leucokeratosis is at the first that of a pure hyper- 
keratinization of the epithelium, the resulting thickening being the 
starting-point of the fissure or erosion which later, by inflammatory 
processes, becomes the focus of a new cell-growth. Later, epithelial 
pegs pass downward and penetrate the inflamed derma, when lobules 
of the new growth are formed, containing epithelial globes. Leloir 
insists that the epitheliomatous process always begins, not at the level 
of the hyperkeratosis of the mucous membrane, but below the fissure 
or other lesion induced by the induration of the plaque or streak, 
indicating in other words that the epitheliomatous change is rather 
an accident than an essential part of the process. 

The Diagnosis is chiefly from syphilitic lesions of the mouth, which 
should be recognized as a rule by their softness and tendency to 
ulcerate, as well by their situation, which is far less distinctive than 
in the case of leucokeratosis of the mouth. A history of infection 
and of symptoms of the disease in other regions of the body would 
usually indicate the nature of the process. 

The only other malady likely to be confounded with leucokeratosis 
of the mouth is lichen planus ; and I have been for a long time con- 
vinced that some confusion exists on this point in all descriptions of 
the two diseases. 

In lichen planus of the inside of the lips, over the tongue, the 
palate, and other parts, dense, smooth or fissured plaques, rings, 
festoons, linear stria?, or disks may be recognized covered by a silver- 
whitish pellicle. It is clear that the distinction between these and 
leucokeratosic lesions is in a high degree obscure, and for the present 
the most that can be done is to search with special care for other 
symptoms of disease upon the cutaneous surfaces of the body pointing 
to either lichen planus or syphilis. 

The Treatment of leucokeratosis of the mouth is first by abstention 
from all local irritants (tobacco, highly spiced, heated, acetous, and 
iced articles of food and drink), by the care of the teeth, and by the 
employment of soothing sprays or lotions containing the chlorate of 
potash, boric acid, balsam of Peru, iodized phenol, myrrh, or muriated 
iron. 

The nitrate of silver may be applied to any ulcerated or fissured 
points, in both solution aud by sweeping the solid crayons over the 
surface. The French make use of the salicylates in the same way. 

Destruction or removal of the lesions may be secured by the 
employment of caustics, chemical or galvano-cauteric ; by erasion 
with the curette; or by surgical ablation. No method seems to me 
preferable to the use, when practicable, of the burr of the dental 
engine after the injection of the muriate of cocaine. Where the 



686 DISEASES OF THE SKIN. 

patches are not too dense and extensive, this has always, in my ex- 
perience, been most productive of good results. 

The Prognosis is fairly favorable in the case of all subjects of the 
disease who consent to deny themselves absolutely the luxury of 
tobacco-usage in every form and who can follow a prescribed hygienic 
and medicinal course. For all others there is danger of epithelioma, 
and that without exception of any case. 



Sarcoma Cutis. 

Gr., caps, flesh. 

Statistical frequency in America, 0.044. 

Sarcoma of the skin is characterized by the occurrence, either as primary or 
secondary developments, of single or multiple, pea- to egg-sized and larger, 
pigmented and non-pigmented, cutaneous and subcutaneous neoplasms having 
a marked inaptitude for ulceration but malignant in character, recurring after 
extirpation, and usually terminating fatally with involvement of the viscera. 

The term, Sarcoma, meaning a fleshy tumor, was originally em- 
ployed by Yirchow in the designation of this disease. Its anatomical 
features have been carefully studied since by Rindfleisch, Cornil and 
Ranvier, Babes, Heitzmann, and others. 

Cutaneous sarcoma is rare and obscure among cutaneous affections. 
Two groups are readily distinguished : 

(A.) Primary Melanotic Saecoma, or Melano-sarcoma. — 
This is the more common. It may develop from a pigmentary nsevus 
which has been irritated, or from any pigmented point upon the 
integument, especially upon the dorsum of the hands and feet, the 
lower extremities, the genital region, and the face — over the cheek or 
near the orbit, where it may originate from the choroid coat of the eye. 

It may be of primary occurrence or develop as a secondary de- 
posit. The lesions are bean- to egg-sized, usually single or multiple, 
very firm or doughy, sessile or pedunculated, spheroid or lobulated ; 
and vary in color from grayish-brown to deep black. The epidermis 
which covers them may be discolored, thinned, and intact or ulcerated. 
The color may be of any shade to an inky blackness. The nodules 
are often surrounded by blackish puncta which eventually develop 
into tubercles. The lesion or lesions may for a long time remain 
stationary, or may be rapidly followed by generalization, as a result 
of local irritation, either by extension from a central point to adjacent 
tissue, or by transmission through the lymphatics to a distance from 
the primary nodule. 

In a case lately observed by the author, the left lower extremity of 
a middle-aged woman was studded with split pea-sized to marble-sized, 
ink-black masses from the ankle to the middle of the thigh. The 
larger were always centres of groups of similar pin-head sized black 
masses. The skin of the region affected was swollen, inextensible, 



SARCOMA CUTIS. 687 

inelastic, and as firm as sole-leather. The disease had rapidly 
extended from the ankle upward in the course of a few mouths. 

Pathologically, tumors of this kiud are found to exhibit the aua- 
tomical features of sarcoma in general, with pigment distributed both 
within and between the cellular elements of the tumor, and between 
the fasciculi of connective tissue in the framework. It is one of the 
most malignant and rapidly fatal of all neoplasms. Therapy is 
unavailing; and the prognosis is grave indeed, a fatal result usually 
occurring with rapidity after the occurrence of generalization, and 
commonly with visceral complications by reason of secondary 
deposits. 

Melanotic Whitlow (Hutchinson) is described as a chronic 
onychia, displaying some pigment, suggesting nitrate of silver stains 
at the edge of the nail-fold, where eventually a fungous tumor forms 
with increase of pigment till the nail is exfoliated, and the process 
becomes generalized. 

(B.) Primary Non-Melanotic Sarcoma. This occurs in both 
localized and generalized forms. 

The localized form of primary non-melanotic sarcoma is quite 
rare, and seen chiefly in women. As in other sarcomata, it is often 
first recognized at a point where a nsevus or other warty growth has 
become irritated, but more often over the extremities. At such a 
point a firm, dull, whitish nodule forms, having nearly the hue of 
the normal skin, rarely vascularized, which may, after persistence 
without change for a variable period, break down by ulceration and 
become the seat of a fungous vegetation. Generalization of the pro- 
cess may result either spontaneously or from accidental complications. 

The disease, when affecting the skin in multiple lesions, is charac- 
terized by the appearance of several, usually at first isolated, pea- to 
nut-sized and larger, smooth > spherical, irregular, or lobulated, cuta- 
neous or subcutaneous tumors. They may or may not be at first 
attached to the epidermis above and the deeper structure beneath, but 
eventually contract such adhesions. Between them the skin may not 
be involved. In uncomplicated cases at this period, the conspicuous 
features of these lesions are (a) their whitish color, due to their 
envelopment in an unaltered epidermis ; (b) the history of a rela- 
tively rapid development, as distinguished from fibromata, epithelio- 
mata, gummata, and lupous tubercles ; (c) the speedily declared sys- 
temic results of the growth. 

Later, the skin between the lesions becomes swollen, infiltrated, 
painful ; and, even before the tubercles desquamate, enormous tume- 
faction aud redness of an erysipelatous type may affect the internod- 
ular tissue. In this way an entire limb, only one portion of which 
is the seat of the tubercular growth, may attain an elephantiasic size, 
ulcerate at one or more points, and pour out an offensive secretion as 
a consequence of ulceration of the inflamed integument. 

In the course of time, weeks not years, the nodules or tumors of 



688 DISEASES OF THE SKIN. 

sarcoma coalesce, degenerate by ulceration, and participate in the 
process going on in the inflamed and excoriated skin where they are 
implanted. Death results either from exhaustion, intercurrent fever, 
or sarcomatous involvement of one or several viscera. By the same 
process the skin lesions may be the product of metastasis from the 
lymphatic glands or viscera. 

The disease occurs in this form over the chest, extremities, and 
genitalia, though all parts of the skin have been invaded. The 
patient from whom the tumors were removed, whose microscopical 
features are represented in the accompanying illustration, was a 
woman in middle life. 

The disease is both rapid in course and malignant in type. In a 
total of more than fifty thousand cases of diseases of the skin reported 
to the American Dermatological Association, only sixteen were sar- 
comatous, the actual percentage being 0.027. 

Generalized Primary Non-Melanotic Sarcoma of the 
Skin (Idiopathic Multiple Pigment Sarcoma of Kaposi, Tanturri, de 
Amicis, Wigglesworth, Hallopeau, and others) owes its coloring to 
cutaneous haemorrhages. It occurs chiefly in male subjects who have 
been laborers, from forty to sixty years of age, whose hands and feet 
become the seat of an oedema, accompanied by pruritus and other sub- 
jective sensations. Later, brownish, bluish-red, or dark-purplish 
spots appear, out of which pin- head to pea-sized nodules develop, 
gradually increasing in volume, discrete, tender, and often grouped. 
They may be the seat of lancinating and radiating pains. As they 
multiply, a lardaceous infiltration progressively involves the depth 
of the integument, till an elephantiasic condition is produced, the 
hand, foot, or an entire limb becoming of cartilaginous hardness, 
bluish in tint, and covered with a smooth, mammillated, squamous, or 
rugous envelope, which may be also the site of tumors of a consider- 
able size. These are fewer in number and smaller in volume as they 
spread from the distal to the proximal parts of the limb. They may 
be sessile, pedunculated, and grouped ; but are always of a deep-bluish 
or violaceous tint. 

These growths may remain for a long time stationary ; or may be 
entirely resolved, the patient apparently securing complete recovery. 
Very rarely they ulcerate or exhibit slight erosions. At times they 
are covered with or surrounded by telangiectases, or tissue exhibit- 
ing infiltration of blood. When the mucous membranes are involved, 
points, patches, disks, or infiltrations of a dusky reddish or bluish 
shade appear on the inside of the gums, lips, tonsils, or over the 
palate ; and there is visceral involvement with lymphatic and vas- 
cular changes. The usual signs of physical exhaustion ensue, with 
fever, dysenteric symptoms, haemoptysis, and marasmus. The dis- 
ease may last only from three to five years, but a duration of four- 
teen years has been recorded. Post-mortem, tumors have usually 
been recognized in the viscera. Only a very few infantile cases have 
been recorded. 



SARCOMA CUTIS. 



" Kecurrent Fibroid of the Skin" (Hutchiuson), beginning 
usually in the lower extremities, and tending to slow extension, rapid 
and persistent recurrence, and tendency to ulcerate and form fungous 
tumors, with ultimate marasmus, is set down by Crocker as a rare 
form of spindle-celled sarcoma. 

The Etiology of sarcoma is unknown. According to Babes, sar- 
comata are frequently congenital, and not rarely formed in early youth 
on the lids, extremities, and genitalia. 

Pathologically, according to the same author, sarcomata are new- 
formations of embryonal tissue with abundant proliferation of vas- 
cular elements and vessels. As 
to the former, numerous rudi- 
ments of vessels multiply with- 
out developing into complete 
vascular channels, often making 
eventual connection with pre- 
existing vessels. In these there 
may be a complete or incomplete 
production of blood In other 
cases, the parietal portions of 
young blood-and lymph- vessels 
proliferate abundantly in an em- 
bryonal formation of fasciculi 
and alveoli, either choking the 
lumen of the original vessel, or 
transforming it into vacuoles, 
cups, and spaces. 

All tumors of this character 
are abundantly supplied with 
cells, the proportion of which to 
the stroma is markedly in excess. They never resemble embryonal 
and granulation tissues. The cells may be spindle-shaped, spheroi- 
dal, branched, with one or many nuclei, and either large or small. 
The fibrillar basement-substauce, according to Delafield and Prud- 
den, 1 may be present in such small quantity as entirely to escape 
superficial observation ; or so abundant as to suggest the appearance 
of a fibroma. It may be closely inwoven with the cells in such 
bundles, or exhibit wide and open meshes presenting the appearance 
of alveoli. The cells are in intimate relation, and often continuous 
with the basement-substance. Both cells and substance are in the 
same close relation with the vascular elements described above, upon 
which Babes relies so largely for identification of the nature of the 
growth. 

Virchow described originally five varieties of sarcoma : round- 
celled, spindle-celled, net-celled, giant-celled, and melanotic. In 




Sarcoma. Spindle-cells visible in sections of 
cutaneous nodule removed from one of the 
author's patients. (About X 300.) 



Handbook of Pathological Anatomy and Histology, New York, 1885. 
44 



690 DISEASES OF THE SKIN. 

spindle-celled sarcoma the cells may be large or small, and vary so 
greatly in proportion to the stroma as to furnish the subvariety of 
fibro-sarcoma, in which the fibrous tissue abounds between the cells. 
These may be encapsulated or infiltrating. The mass of the tumor 
is then constituted of a decussatiDg felt-work of spindle-shaped, 
nucleated, protoplasmic bodies. 

Round-celled sarcoma is constituted of globular, protoplasmic ele- 
ments closely packed together, and separated by a very narrow layer 
of cement-substauce, traversed by delicate prolongations of the living 
matter which uninterruptedly connect the elements. The vascular 
supply is scanty. There are two forms of this growth found in the 
skin : (a) Those with relatively large protoplasmic bodies and large 
nuclei — large round-celled sarcoma. (6) Those with relatively small 
homogeneous lumps of living matter — small round-celled sarcoma or 
" lympho-sarcoma." The last-named varieties are, as a rule, more 
rapid in growth and more malignant in career than the former. 

In the " alveolar sarcoma," of Billroth, there is a delicate connec- 
tive tissue framework, containing attached globular or pyriform 
bodies. Heitzmann has recognized this form once, in the skin of 
the left groin. 

The compound varieties of the disease, myxo- and fibro-sarcoma, 
are occasionally seen in the skin. The formation of secondary 
tumors is explained, according to Heitzmann, by the transmission 
of minute particles of the neoplasm to capillaries of a fine lumen, 
presumably through the bloodvessels, as the lymph ganglia are 
rarely involved. 

The Diagnosis rests upon microscopical examination of the new 
growth in every case. Sarcoma should not be confounded with 
fibroma, epithelioma, gumma, or lupous nodules. 

Treatment is highly unsatisfactory. Surgical ablation of these 
tumors is apt to be followed by their speedy return. 

Koebner's injections of arsenic (usually Fowler's solution, two to 
four drops in one to two parts of distilled water, repeated every sec- 
ond day for months, with gradual increase of the dose) seems to have 
proved successful in two cases. Arsenic, potash, and ergot, inter- 
nally ; and salol, camphorated naphthol, aristol, and bismuth subni- 
trate locally, have secured only transitory results. 

The Prognosis is exceedingly unfavorable, a fatal issue occurring 
in most cases. 



MYCOSIS FUNGOIDES. 691 

Mycosis FuDgoides. 

Gr., fJ-vx-JK, a mushroom. 

(Granuloma Fungoides ; Granuloma Sarcomatodes ; Inflammatory 

Fungoid Neoplasm ; Eczema Tuberculatum ; Fibroma 

Fungoides ; Lymphodermia Perniciosa ; Sarcoma- 

tosis Generalis. Fr., Lymphadenie Cutanee.) 

Mycosis Fungoides is an infective disease, characterized by various cutaneous 
phenomena which result finally in the production of one or several well- 
defined, firm, reddish tumors, probably due to the presence of specific micro- 
organisms. 

This disease was first described by Alibert, in 1 814, as " Pian 
fongo'ide." Its symptoms resemble that affection in an obscure 
degree, though not in any way related to it. 

The disease is rare, but cases have been of late so carefully ob- 
served and so fully reported, that dermatologists are now familiar 
with most of the symptoms of the disorder. My personal experi- 
ence has been limited to four cases ; two seen in Paris ; one repre- 
sented in the appended illustration, and another occurring in a female 
subject under my observation for two years, presenting an extreme 
type of the disease. An attempt has been made to distinguish 
between two forms. There is, however, but one ; and this may or 
may not be preceded by what has been called the pre-mycosic stage. 

Symptoms. — The so-called pre-mycosic stage is characterized by 
the occurrence of a series of dermatoses of different type, erythema- 
tous, urticarial, psoriasiform, usually in patches with and without 
definition, circumscribed and vivid in hue ; or diffuse and dull 
reddish ; palm-sized, coin-sized, or punctate. These are probably 
symptomatic, for the mycosic plaques do not necessarily spring from 
areas of the skin thus involved, though there is a possibility that 
this may be the case at times. The so-called pre-mycosic stage may 
last for months or years. It may be wholly absent. Its absence 
may not increase the portentous character of the malady. 

The earliest symptoms of the disease proper are circumscribed infil- 
trations, button-sized to palm-sized and larger, often intensely pruritic, 
rosy-reddish or having a highly characteristic pinkish-red hue, which 
exhibit a warty surface, often scratched, fissured, and as a consequence 
hemorrhagic, or here and there stained with blood-crusts, particularly 
in the more advanced stages of the disease (lichenoid plaques, of 
Bazin). These may disappear, leaving very peculiar circumscribed 
vitiliginous plaques where they existed ; or the tumors described 
below may develop from them ; or they may be in full development, 
furnishing no tumors, when the latter are growing with mushroom- 
like rapidity from other parts of the body, more particularly over 
the face ; or, lastly, defined circumscribed areas, destitute of pigment, 



692 



DISEASES OF THE SKIN. 



resembling leucodermatous patches, may occur in the skin where 
there has been no warty plaque. 

In a variable period of time, the characteristic tumors of the disease 
appear upon the face, scalp, chest, and other portions of the body. 
They are bean- to palm-sized ; whitish, pinkish, or pale reddish in 
hue ; firm, well-rounded, and distinctly circumscribed. Often they 
are like flat buttons, movable within the skin. They may then dis- 
appear by absorption while others appear ; may degenerate by erosion 
leading to superficial ulceration ; or may melt down into deep losses 
of tissue by ulceration. Coincidently the lymphatic glands may 
enlarge, and this adenopathy, as in case of the tumors, subside to be 
replaced later by similar involvement of the same or other glands. 



Fig. 90. 




Mycosis fungoides. (Drawn from an oil painting taken at the bedside of 
one of the author's patients.) 

When the tumors have attained maturity and before involution 
has begun, their appearance, especially upon the face, is characteristic. 
They are smooth, moderately firm, sausage-like in shape, often 
lobulated, of a peculiarly reddish hue, and produce when numerous, 
a lepra-like deformity, closing the eyes by their size or weight, pro- 
ducing the leonine brow and the elephantiasic ear. In the author's 
case illustrated in the cut 1 the body of the patient was extensively 
covered with tumors of all sizes, resembling those seen on the face. 

The general condition of the patient at first seems unaltered ; 
later, when the tumors ulcerate, exhaustion occurs and the victim 
usually dies, as in other cutaneous disorders of similar gravity, as a 






Edinburgh Med. Journ., 1883-1884, xxix., p. 592. 



MYCOSIS FUXGOIDES. 693 

result of febrile processes, or of an intercurrent diarrhoea, or of 
cachexia. When the tumors are many and the ulceration extensive, 
the appearance of the patient is repulsive in the extreme, the exhala- 
tions from the body in the highest degree fetid, and the difficulty of 
securing antisepsis, hygienic care, and comfort for the wretched 
sufferer well-nigh insurmountable. 

The fully developed tumors occur upon all parts of the body, upon 
the palmar and plantar surfaces, the arms and forearms, the thighs 
and legs, the face, and the back. Often they are in various degrees 
pigmented, showing then purplish, brownish, or even black colors. 
They are usually painful, and may or may not be tender. They 
sometimes, after disappearing, leave atrophic or pigmented depres- 
sions as relics of their career. They are said to ulcerate rarely. In 
one of the author's patients ulceration attacked some of the tumors, 
leaving crateriform excavations in their centres, but this was an ex- 
ception to the rule, the larger number present preserving their shape 
in death. In a few, vegetations appeared upon the summit, smeared 
with a thin and very offensive secretion. 

When the tumor is single, and apparently uncomplicated by in- 
volvement of deeper organs, extirpation is usually followed by recur- 
rence, either in the scar or vicinity, with added malignancy. 

On the backs of the hands the lesions may be no larger than small 
marbles, with infiltration of the skin lying between the latter, pro- 
ducing thus the appearances of a small, well-rounded cushion. The 
epidermis of such an cedematous hand usually exfoliates in silvery- 
white or grayish scales, more or less adherent. The feet and legs 
may exhibit a similar appearance. 

The disease has been studied abroad by Hebra, Kaposi, Geber, 
Alibert, Fox, Ivobner, Auspitz, and others ; in this country by 
Duhring, Piffard, Wigglesworth, Tilden, 1 and the author. 

Etiology. — The disease is fortunately rare. Dr. Tilden collected 
the records of thirty cases of the disease and of sixteen deaths. 
Twenty -three patients were males, and seven females ; more than 
half the whole number were over forty years of age ; in only one 
fourth of the number had the disease developed before the twentieth 
year of life. There can be little question to-day as to its infectious 
character. It is probably produced by a specific micro-organism. 

Pathology. — Under the microscope, sections of tumors removed from 
patients affected with the disease, exhibit infiltration of the corium 
and subcutaneous tissue with small round cells arranged in circular 
or irregular groups, enclosed in a narrow stroma of fine connective 
tissue fibres, with often a centrally situated bloodvessel. The epi- 
dermis, at first spared, is afterward involved by ulceration. Accord- 
ing to Gannett, who examined sections in Tilden's case, the cells 
corresponded, morphologically, to lymph-corpuscles. 

The micro-organisms of mycosis fungoides have been recognized 

1 Consult Dr. Tilden's monograph on the subject, in the Boston Med. and Surg. Journ., of 
Oct. 22,1885. 



694 DISEASES OF THE SKIN. 

by Kindfleisch, Auspitz, 1 and others. An exhaustive report on the 
subject has been made more lately by Auspitz's collaborators, Messrs. 
Hochsinger and Schiff; 2 and Professor Firket, 3 of the University of 
Liege, reports yet another case, illustrated by a photograph, in which 
micrococci were recognized. These are diplococci or streptococci, 0.9 to 
1.2 micromillimetres in diameter, and found in clusters both in tumors 
and in bloodvessels. They were found not only in the protoplasm 
of the cells, from ten to twenty in each, but also thickly spread along 
the connective tissue fibres in the neoplasm. These were cultivated 
successfully for a series of generations in gelatine and blood-serum. 
Post-mortem examination has rarely shown visceral involvement. 

The Diagnosis of mycosis fungoides cannot be made with certainty 
before the characteristic tumors have been developed. After that, 
the peculiar shape, reddish color, situation, and relative rapidity of 
the growth point to the nature of the disease. 

From lupus vulgaris, with which it may be confounded in view of 
the age of the patient, it may be recognized by its relative rapidity 
of evolution, its failure to ulcerate at an early stage, and the absence 
of cicatrices in cases where there has been no operative interference. 

Syphilis is to be distinguished by its history, its multiformity, its 
ulcerative type, and its amenability to specific treatment. Lepra 
does indeed, when occurring in its rare and acute forms, suggest 
mycosis fungoides of the face. But the presence or history of hyper- 
sesthetic or anaesthetic symptoms, of bullous or macular lesions, and 
the absence of deforming mutilations in advanced periods, will usually 
point to the nature of the disease. The tubercles of lepra are smaller 
than the tumors of mycosis fungoides ; more bronzed and less fleshy 
in color • and of far less general distribution than in several cases of 
the last- mentioned disease on record. 

The Treatment is unsatisfactory. With the knowledge now pos- 
sessed as to the nature of the disorder, the bichloride of mercury 
would certainly be indicated in the local management of the disease. 

The comfort of the patient is to be secured by all measures, in- 
cluding anodynes in an advanced stage of the disease, and the strength 
should be supported by a generous diet and tonic regimen. When 
the disease is generalized, tepid baths are productive of great comfort ; 
and the use of boric acid, resorcin, aristol, carbolic acid, or some 
similar agent, is indicated by the fetor arising from the person. The 
body should be anointed with a bland unguent after each bath. 
When the lesions are single or few, it is doubtful whether extirpation 
should be practised. 

The Prognosis is unfavorable. The patient may survive from a 
few months only, to a maximum of fifteen years, the average being 
two to four years. 

i Viertl. f. Derm. u. Syph., 1885. - Ibid , 1886. 

s Ann. de la Soc.Med. Chir de Liege, 1886. 



PRURITUS. 695 



CLASS VII. 

NEUROSES. 
Hyperesthesia. 

Gr., inrepj above; cuadqaig, sensibility. 

This is a condition characterized by exaggerated sensibility unat- 
tended by structural changes in the skin. It may be idiopathic or 
symptomatic, general or partial, unilateral or bilateral, and may also 
vary greatly in the degree of abnormal subjective sensation by which 
alone it is declared. In mild cases, there is unusual sensitiveness to 
contact with foreign bodies, such as the clothing ; in others, the dis- 
tress occasioned by even the passage of a feather over the surface is 
almost intolerable. The symptomatic variety of the malady is most 
common, occurring as one of the several manifestations of hysteria, 
tetanus, and other nervous disorders, including certain forms of motor 
paralysis where sensation has been retained, though in a perverted 
condition. The disease is properly classed with the neuroses of the 
skin, with respect to whose etiology and pathology much remains to 
be investigated. Its chief manifestations are the production of 
itching and pain. 

The former is much more frequently experienced in the skin than 
the latter ; and is an almost constant symptom of active cutaneous 
hyperaemia and exudation. The paresthesias (in which sensations of 
heat, formication, tickling, dripping or pouring of liquids of various 
temperatures are experienced) are more often associated with extra- 
cutaneous affections. 

Pain, solely and simply limited to the skin, is, in fact, a neuralgia 
of a nerve having a cutaneous distribution. 



[A.] Pruritus. 

Lat., prurire, to itch. 

Statistical frequency in America, 2.12. 

Pruritus is a functional disorder of the skin, characterized by the sensation of 
itching in a part or a whole of the body, and unaccompanied by objective symp- 
toms of disease, save those produced by attempts to relieve the local distress. 

Symptoms. — Pruritus is to be distinguished not only from prurigo, 
a rare disease of the skin already described, but also from the symp- 
tomatic sensation of itching which is occasioned by a number of 
cutaneous disorders, such as eczema, scabies, and those produced by 
pediculi. Hebra was first to recognize the independent character of 



696 DISEASES OF THE SKIN. 

the disease here considered ; but it is to be regretted that he did not 
give to it a Dame distinct from that which is also applied to a symp- 
tom common to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced 
originally by cutaneous lesions. It may be general or partial. In 
either form, it begins usually by a tickling, pricking, crawling, or 
itching sensation in the skin, which solicits the sufferer to rub, press, 
scratch, or otherwise irritate the affected integument. It usually 
occurs by accesses in the day or night, much more often the latter, 
occasionally both ; and these accesses manifestly occur under the 
immediate stimulus of some internal or external cause. Thus, moral 
emotions, a cool draught of air, the warmth of the bed, the pressure 
of clothing, and often the substances applied externally with a view 
to the relief of the pruritus, suffice to determine a crisis. However 
firmly the sufferer may determine to avoid injury to the person, in 
well-marked cases the impulse to scratch becomes well nigh irresistible, 
and, in the highest degree, tormenting. From the milder, the patient 
will thus be frequently teased to inflict the severer injuries upon the 
skin. Brushes, combs, coarse cloths, and even metal instruments, 
will be employed in exaggerated cases, for the purpose of assuaging 
temporarily the local distress. 

The objective cutaneous symptoms which may be presented are all 
secondary, and invariably result from self-inflicted injury. In some 
cases they do not appear, the statements of the patient being the sole 
basis for a recognition of his disease. This may be the consequence 
of unwonted self-control, or of the mildness of the malady, or of the 
transitory character of the lesions produced. Thus the skin may be 
reddened during a nocturnal paroxysm under the manipulation of 
the sufferer, and the transitory hyperemia disappear in the daytime 
when the skin is submitted for inspection. Not rarely, however, the 
integument resents the treatment to which it is subjected, by dis- 
playing wheals, hyperaBmic blotches, reddened papules, excoriations, 
characteristic " scratch lines/ 7 and the minute blood-crusts which 
indicate that the papillary layer of the derma has been reached and 
slightly torn. As these causes are among those recognized for eczema 
and dermatitis, it is not surprising to note that such disorders of the 
skin may be in this way originated, and still further add to the sub- 
jective distress. Skins which have been for years the seat of a per- 
sistent pruritus leading to traumatisms of the epidermis, are always 
deeply pigmented. 

The localized forms of pruritus, albeit the abnormal sensation is 
in them limited to certain regions of the body, may occasion fully as 
much distress as those in which a larger part of the integument is 
affected. They are of more frequent occurrence than the generalized 
forms. Pruritus of the anus, of the scrotum, of the vulva, of the 
vagina, of the scalp, of the nose, of the mouth, of the axillae, are all 
localized forms of the disease, two or more of which may coexist or 
develop in succession. 



PRURITUS. 697 

Pruritus Narium is a frequent symptom of irritation of the 
Schneiderian membrane. It is thus a common precursory or at- 
tendant phenomenon of rose- or hay-asthma; and in some individuals 
announces the systemic effect of opium and its alkaloids after inges- 
tion. It occurs also in children as a result of pediculosis of the 
scalp. It may result, further, from the irritation awakened by intes- 
tinal parasites. 

Pruritus Genitalium is often an exceedingly severe and distress- 
ing affection. As the parts in question are apt to be rubbed and 
scratched in the efforts to secure relief of the itching sensation, 
orgastic effects and pollutions are often produced in early youth and 
extreme age, whose moral effects are degrading. The scrotum, labia 
majora and minora, penis, clitoris, and adjacent cutaneous and mucous 
surfaces may be the seat of the pruritus. Search should always be 
made, in such cases, for ascarides of rectum or vagina, saccharine 
urine, and uterine or ovarian affections. A perverted sexual hygiene 
may lie at the root of these disorders. In severe eases, the violence 
with which the parts are attacked suggests frenzy on the part of the 
patient, w r ho at times is never content till the scrotum or other parts 
are bathed in blood. The thickening, erosions, and excoriations of 
the regions attacked, are conspicuous features of the disease. 

Pruritus Axi. — This is a disorder of adults of both sexes, and 
may coexist with pruritus of the genital region. There is usually 
nocturnal exacerbation. The anus may become infundibuliform from 
induration ; its mucous surface excoriated ; its cutaneous borders 
seamed, puckered, eroded, and fissured. It is often complicated with, 
because the origin of, an eczema whose lesions reach upward over the 
coccyx or forward to the genital region over the perineum. Haemor- 
rhoids, ascarides, chronic prostatitis, rectal impaction, proctitis, un- 
natural vices, gout, alcoholism, and diabetes may each be responsible 
for its occurrence. In all exaggerated forms of pruritus cutaneus, 
the general health perceptibly fails. Whether from prolonged in- 
somnia arising from the nocturnal exacerbations to which there are 
but few exceptions ; or from the perversion of nutrition incident to 
the continuous teasing of the nervous system ; or yet from the hypo- 
chondriacal state into which some patients are plunged by their 
sufferings, such an issue is often to be expected. It is in fact a com- 
plication which may merit, as much as the disease itself, the attention 
of the physician. 

Pruritus Palm^e et Pla:ntje is a rare form of this disorder, in 
which the itching is limited to the palms and soles. It may com- 
plicate gout, malaria, hyperidrosis, and asthma. 

Etiology. — The causes of pruritus are numerous, and the necessity 
for the discovery of the particular cause in each patient, often makes 
the largest demands upon the practitioner. The disease may occur 



698 DISEASES OF THE SKIN. 

at all periods of life and in both sexes, but its exaggerated forms are 
peculiar to middle life and advanced years (Pruritus Senilis). It 
is frequently a reflex symptom of one of several internal disorders. 
Among the latter may be named, malarial affections, tuberculosis, 
carcinoma of the viscera, disorders of the liver or kidneys (especially 
jaundice, Bright's disease, and diabetes), and disturbances of the 
alimentary canal, including those due to intestinal worms, haemor- 
rhoids, and dietetic or medicinal ingesta. It may be associated with 
almost every one of the functional, and not a few of the organic, dis- 
orders of the uterus and ovaries. The same may be said of its 
dependence upon the genito-urinary diseases of the male sex, includ- 
ing stone in the bladder, stricture of the urethra, disorders of the 
testes and epididymis, and perverted sexual hygiene. 

Lastly, the moral emotions of a depressing character play an im- 
portant part in the etiology of pruritus. Mental distress, occasioned 
by bereavement, separation from relatives, misfortune of all sorts, 
and anxieties as to the future, often find physical expression in the 
disease. 

Pathology. — The disease is essentially a functional disorder of the 
nerves of sensation supplied to the skin, and is of itself incapable of 
producing objective symptoms. This fact can, in some cases, be 
clinically demonstrated, as the seat of the pruritus, even though 
exhibiting artificially produced lesious, will, when protected from all 
external injury, speedily regain its normal appearance, the pruritus 
no less continuing. It is probable, though not certain, that the 
nerves also in this disease uudergo no structural change, but merely 
convey to the periphery a perverted sensation which is often reflected 
from some centric point of disturbance. 

Diagnosis. — The recognition of general pruritus is usually not 
difficult, as the secondary results of the disease are apt to be less 
marked than in its other forms. The complaint of the patient, the 
absence of cutaneous disease sufficient to explain the symptoms, and 
especially the discovery of such a sufficient cause in some visceral 
or systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible 
only when the clothing of the patient is entirely removed. It then 
becomes evident to the eye that the affected regions are, in order of 
frequency, those most accessible to the hands. The posterior are 
much less involved than the anterior surfaces. The small of the back 
and interscapular regions are usually untouched. The tibial regions 
of the legs and the skin of the forearms suffer more than the calves 
and the upper arms. The lower belly and inner faces of the thighs are 
punished more severely than the breast and outer faces of the thighs 
and the hips. The clavicular regions are more excoriated than the 
back of the neck. There is no more precise evidence than this as to 
the pruritic character of any cutaneous affection, and it is one too 
often ignored by the practitioner who prescribes under those circum- 
stances for a " disease of the blood.*' 

It must be admitted, however, that when the disease is localized. 



PRURITUS. 699 

and complicated, as it frequently is, by an eczema or dermatitis, 
doubt may arise. Attention should then be paid to the history of 
the disorder, which may reveal the fact that the pruritus preceded 
for some time the cutaneous symptoms, and may disclose even more. 
Intelligent patients will often assure the physician of the real nature 
of the malady, by voluntarily remarking that the skin symptoms 
disappear upon the region which is not scratched, though the pruritus 
continues. In all cases the operation of exterior agencies should be 
carefully eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its 
severe itching, beginning in early infancy and commonly persisting 
through life, can scarcely be confounded with pruritus cutaneus. 

Treatment. — The degree of success to be obtained in the treatment 
of pruritus cutaneus is largely proportioned to the skill with which 
the cause of the disease is recognized and remedied. Taking into 
consideration the number of systemic and visceral disorders which 
may be, in different cases, responsible for the skin symptoms, it is 
clear that an exhaustive study of the mental and physical history of 
each patient will be essential at the onset of treatment. The cause 
once recognized, the treatment should be directed to the special dis- 
order discovered ; and this largely requires the skill of the general 
practitioner. The gastro-intestinal tract, the kidneys, the liver, the 
bladder, the uterus, the prostate gland, the rectum, and indeed any 
one of the viscera, may require therapeutic management. For the 
frequent gastric disorders, the alkalies and alkaline waters, with 
occasional cathartics and strict regulation of the diet, are often useful. 
Attention should be particularly directed to any medication to which 
the patient may have been subjected with a view to a therapeutic 
effect, and which may have aggravated the complaint. The mineral 
acids, chalybeates, pepsin, lactopeptin, quinine, strychnine, phosphorus, 
arsenic, or atropine may be indicated in individual cases and produc- 
tive of favorable results. 

The substances which have been topically employed for the relief 
of pruritus cutaneus are almost without number, a fact warranting 
the conclusion that each occasionally fails to afford the desired relief. 
This is corroborated with every wide clinical experience ; that prepa- 
ration, moreover, which is at one time of the highest value, will dis- 
appoint at another period in the history of a single case. Attempts 
to secure relief by such topical applications should, however, be 
always made, and will often be followed by gratifying results. 

First in order of value are baths and lotions of water, hot, warm, 
or cold, or alternately hot and cold, and medicated by the addition 
of the sodic bicarbonate or biborate, the potassic carbonate or sul- 
phuret, varying in strength from one ounce (32.) of the last-named, 
to six ounces (192.) of the first-named substance, in thirty gallons of 
water. Gelatin or bran may often with advantage be added to 
these, as suggested in the chapter on general therapeutics. Alcoholic, 
ethereal, camphorated, and carbolated lotions are to be regarded as of 



700 DISEASES OF THE SKIN. 

equal value. Duhring specially recommends solutions of carbolic 
acid, in the strength of from five to twenty grains (0.33-1.33) to the 
ounce (32.) of water, to which a half drachm (2.) of glycerin has 
been added. Rohe simply employs boric acid, one drachm (4.) to the 
pint (512.). 

Van Harlingen adds the anti-pruritic effect of potash as follows : 



J&. Acid, carbolici 


3j; 


4 


Potassse fus. 


3ss; 


2 


Aq. dest. 


Oss; 


256 



M. 

Baths and lotions of this character usually procure merely tempo- 
rary relief; and the treatment in the interval of their application 
demands the wparing of soft linen or other unirritating material 
next the skin, and the free use of a dusting-powder. Those of pure 
starch are here less useful than those compounded with oxide of zinc 
and bismuth, as in the "Anderson powder." Gorecki 1 mingles the 
starch with perfectly pure boric acid. 

Dr. R. W. Taylor, of New York, in a valuable paper, 2 gives the 
following formulae : 

&. Potass, sulphuret. J5 iij ; 12 

Camphor, spts. f ^ ss ; 16 

Glycerin. f gj ; 32 

Aq. font q. s. ad f ^vj ; 192 M. 

Sig. For external use as a lotion, to be applied by the medium of a saturated 
strip of lint. 



R. Spts. camphor. f^ss; 3 6 

Boracis % ij ; 8 

Glvcerin. f % ij ; 64 

Aq. fluv. |vj; 192 

Sig. To be well shaken and applied externally. 



M. 



Morphia, in the strength of one grain (0.066) to the ounce (32.), 
may be added to this and other lotions. 

Chloral-camphor, a pungent, syrupy liquid obtained, as suggested 
by Bulkley, of New York, after triturating an equal amount of the 
two substances in fine powder, is an antipruritic remedy of value in 
certain cases applied in a salve containing one drachm (4.) to the 
ounce (32.) of salve, and is comparable in its action to phenol-cam- 
phor, described in the chapter on general therapeutics. 

Other lotions may be made to contain corrosive sublimate, one- 
quarter of a grain (0.016) to the ounce (32.); dilute hydrocyanic acid, 
or menthol, a drachm (4.) to the half pint (256.); Goulard's extract, a 
drachm (4.) to the pint (512.); chloroform, sulphur, alum, oil of pep- 
permint, dilute nitric, acetic, or salicylic acids, tannin, or zinc sulphate 
in due proportions. 

Often aqua calcis, medicated with calomel, zinc oxide, bismuth, 
or calamine, answers well, and, if tolerated at all, the addition of 
linseed oil, four ounces (128.) to the pint (512.), with a drachm (4.) 

i Le Praticien, Oct. 3, 1881, p. 473. 

2 On the Various Forms of Pruritus Cutaneus, and their Treatment. Arch, of Clin. Surg. 
Rutlege & Co., 1877. 



PRURITUS. 701 

of one of the inert substances named, flavored with rosemary or 
bergamot, will aid in relieving the local distress. 

Ointments and fatty substances in general are usually not well 
tolerated in cutaneous pruritus. Occasionally, however, they are of 
more value than lotions, and may be made to contain one or more of 
the substances named above, such as carbolic acid, five grains to fif- 
teen (0.33-1.) to the ounce (32.); subnitrate of bismuth, a scruple 
(1.33) to the ounce (32.); chloral camphor, five minims (0.33) to the 
ounce (32.); and calomel or ammoniated mercury (especially in 
pruritus ani) five to ten grains (0.33-0.66) to the ounce (32.) of cold 
cream, petroleum ointment, or lard. 

Tarry substances may not be well tolerated in the disease, and 
are, as a rule, when the skin is sound, objectionable as liable to irri- 
tate. Duhring, however, speaks well of the liquor carbonis deter- 
gens, in the strength of a drachm (4.) to two ounces (64.) of water. 
This alcoholic solution of coal tar has been for some time in the 
market of our large cities. The liquor picis alkalinus may be simi- 
larly employed. Special attention has been directed by many writers 
to the treatment of the local forms of pruritus, the principles of 
which have been in the main described above. 

For pruritus of the vulva, Wiltshire 1 recommends decoctions of 
almond meal, marshmallow, slippery elm, and rice ; and in cases of 
failure of the latter, an infusion of tobacco two ounces (64.) to the 
pint (512.). Vaginal injections of hot water and tampons or cocoa- 
butter suppositories medicated with opium, belladonna, or carbolic 
acid are also available. 

Many of the medicaments named above are also useful in pruritus 
of the ano-genital region. The application of very hot water is of 
decided service. Exception should be made here to the rule with 
regard to the exclusion of tars generally from the treatment of pru- 
ritus ; as in the distressing itching of the scrotum and anus especially, 
they are often essential. The tincture of tar, oil of cade, and oil of 
white birch will here often be needed. Pencilling any existing 
fissures with the compound tincture of benzoin or nitrate of silver 
is serviceable. The scrotum when attacked, usually requires the use 
of a suspender, or suspensory bag, lined with soft lint or borated 
cotton, which may also be incorporated with a dusting powder, wetted 
with a lotion or smeared with an unguent. 

Simon has successfully employed pilocarpine in cutaneous pruritus, 
both internally and by hypodermatic injection. Fur the latter, the 
muriate of pilocarpine is used in doses of one-sixth of a grain 
(0.011). The same author has administered with good results a 
syrup of jaborandi, made in the proportion of three parts of the 
leaves of. the plant to fifteen of water, aud eighteen of dissolved 
white sugar, of which two tablespoonfuls are taken at a dose. 

In Europe, the favorite local application for relief of pruritus is 
a lotion containing tar in some form. Usually from five to ten per 

i Brit. Med. Journ., March 5, 1881, p. 328. 



spirit lotio 


q. Sal 


icylic 


acid is 




4 
64 
96 




M. 


3Jss ; 


6 






aa ^v; 


20 






3*; 


40 




M. 



702 DISEASES OF THE SKIN. 

cent, of glycerin is employed in a spirit lotion 
often substituted for it : e. g.: 

R . Acid, salicylic. 
Spts. vin. rectif. 
Aq. dest. 
Sig. Lotion. 

Schwimmer recommends : 

R . Alumin. hydrat. 
Glycerin. \ 
01. oliv. J 
Ungt. moll. 
Sig. Ointment. 

Thin lotions of starch-water or oatmeal gruel, iced or cooled in 
hot weather, to each pint of which a drachm or more of the zinc 
oxide, or subnitrate of bismuth may be added, are often of imme- 
diate value. 

Iodoform, the oleate and muriate of cocaine, the latter in from 
two to four per cent, solutions ; one ounce (32.) of the fluid extract 
of coca, to two or four of water ; and linseed oil (especially for 
pruritus ani), are also recommended. 

Jul lien recommends in pruritus of the vulva : 

R . Zinci oxid. 3 vj ; 24 

Acid, salicylic. gr. xv ; 1 j 

Glycerin. 3 vj ; 24 j M. 
Sig. Apply as required. 

Cheron, in pruritus of the vulva attending the menopause, has 
successfully used : 

R. Veratrise gr. iij ; i266 

Axung. 3j; 32| M. 

He also administers in pill form, one one-hundred-and-twentieth 
of a grain of veratria rubbed up with licorice. 
Squibb's formula is : 



M. 



Lastly, it should not be forgotten that many cases of intractable 
pruritus are best managed when the attention of the patient is 
diverted from the malady by the distraction incident to travel, aided 
by change of scene and climate. 

There are strong reasons for refusing to employ in pruritic dis- 
orders preparations containing cocaine, cannabis indica, conium and 
others of similar character intended to relieve the subjective sensa 
tions by internal medication. Many well-nigh incurable cases of 
the " cocaine-habit " have been begotten by treatment of this sort 



R . Acid, tannic. ►) j ; 


1 


Glycerin. j - 
Spts. vin. rectif. j d ' 


16 


Aq. dest ad f ^iv; 


128 


Sig. Apply morning and evening on a rag. 





PRURITUS. 703 

when the patient, often a nervous woman with an intolerable pruri- 
tus vulvae, is in a condition peculiarly susceptible to the action of 
remedies of this class. The latter should always be regarded as the 
last resort of the practitioner, and a confession of his own weakness 
in not discovering the special cause effective in the case with which 
he is for the time confronted. 

Prognosis. — Pruritus senilis is usually an intractable disorder, and, 
when dependent upon senile alteration of the cutaneous tissues, is 
incurable. For all other forms of the disease a prognosis should be 
formulated with reserve. Under the influence of systematic and 
appropriate treatment, the happiest results are often obtained. Other 
cases, especially those associated with hypochondriasis, may bid 
defiance to all remedial measures. Relapse of the local forms of the 
malady, especially of that of the ano-genital region, is sufficiently 
common. In many of these patients the treatment serves merely to 
palliate the disorder, which recurs with every renewal of the cause. 

Pruritus Hiemalis, Prurigo H ye m alls, " Frost-itch," or 
Winter Prurigo. — Under the first title, Duhring 1 described a 
harsh and pruritic condition of the skin, essentially unattended by 
structural alteration, invading all surfaces of the body, but chiefly 
the inner faces of the thighs, the calves of the legs, and the neighbor- 
hood of the joints of the lower extremities, usually occurring in the 
autumn, and continuing until the following spring. It possesses 
many features in common with the forms of pruritus already de- 
scribed, including variability in the subjective sensations awakened, 
nocturnal exacerbation, and the absence of a primary eruption. The 
secondary results are also similar, being sequelae of self-inflicted 
injury in the form of roughness, peri-follicular redness and papula- 
tion, torn and fractured hairs, excoriations, blood-crusts, and, in 
severe cases, an induced dermatitis. It, however, abates in severity 
with a rise of atmospheric temperature, though the author has occa- 
sionally noted persistence of the distress after such weather changes. 
The affection, moreover, is one which occurs in persons otherwise 
enjoying perfect health, in those of every social grade, irrespective of 
the character of the clothing worn and of the habitual use or neglect 
of the bath. It is, without question, a disease of northern climates, 
and more particularly of climates like our own, where the variations 
of temperature between the extremes of the summer and of the winter 
range between one hundred and one hundred and twenty-five degrees 
Fahrenheit. The careful description by Duhring presents a picture 
whose accuracy is verified by clinical observation, and which justifies 
the recognition of the disease as a form of cutaneous pruritus. Its 
treatment is that detailed above, the author named laying stress upon 
emollient unguents, glycerin in the form of lotion or ointment, and 
alkaline baths. In my experience, the dusting powders, when em- 

1 Phila. Med. Times, January 10, 1874. See, also, a later but independent observation by Mr. 
Hutcbinson : Lectures on Clinical Surgery, 1878, vol. i., pt. 1, p. 100. and Brit. Med. Journ., 1875, 
ii. p. 773. 



704 DISEASES OF THE SKIN. 

ployed after the tepid bath, have proved more serviceable than any 
fat-containing substances. 

Prairie Itch. — This is a popular term applied largely in the 
Western, Northwestern, and Southern States of this country to a 
cutaneous affection productive of itching sensations. It is supposed 
to be the disorder popularly described also as the " Texas Mange/' 
" Ohio Scratches/' " Swamp Itch," " Lumberman's Itch/' etc. 
A parasitic origin has been claimed for it by several observers, who 
also insist upon its contagious character and its curability by para- 
siticides. 

The personal experience of the author has led to the conviction 
that these terms are loosely applied to a group of cutaneous symp- 
toms of diverse origin. The most frequent by far is a pruritus, of 
the kind described above as pruritus hiemalis, occurring in the au- 
tumn, winter, or spring of the year, and aggravated by the coarse 
and cheaply dyed woollen undergarments of the poor and hard-work- 
ing inhabitants of the lumber camps, mining districts, etc. With 
these causes in full operation, there is often aggravation after swallow- 
ing drugs for relief of the pruritus based upon the idea of " purifying 
the blood." 

With these cases occur those of undoubted scabies, for the study 
of which the reader is referred to the chapter devoted to that subject. 
The proportion between the purely pruritic and purely parasitic cases 
of this class cannot be definitely determined. It probably differs in 
different places and seasons, the proportion of cases of scabies increas- 
ing in the lumber camps when they are reinforced by newly arrived 
immigrants infested with acari. It decreases to probably not more 
than from one to two per cent, of all skin diseases in the interior 
villages and towns of the West and Northwest where there has been 
no immigration for some length of time, and where, after the first 
onset of sharply cold weather in the autumn, a large part of the in- 
habitants suffer from pruritic sensations in various degrees. 

A review of the somewhat scanty literature on this subject 1 sug- 
gests the conclusion that the disorder thus popularly designated is 
far more rare in Europe than in America. It is possible that the 
situation of those parts of the United States where this group of 
skin affections seems to prevail (at a great distance from proximity to 
the seashore, and still further separated from the Gulf Stream) may 
play an important part in the extraordinary sensitiveness of the 
skin to climatic changes. Certain it is that a great number of these 
affections are entirely relieved by removal to a suitable climate, more 
particularly to one of the Eastern, Southern, or extreme Western 
States. 

1 See two papers by the author, entitled "On the Affections of the Skin, Induced by Tem- 
perature Variations in Cold Weather." Chicago Med. Journ. and Examiner, March, 1885, 
and February, 1886. Obersteiner: Wien. med. Wochenschrift, No. 16, 1884. Brodie : Penin- 
sul. Journ. of Medicine, 1853-54, vol. i. p. 506. Jones : Kansas City Medical Index, 1886, with 
views of several Western physicians. Clark : Medical Age, 1886. Payne : British Medical. 
Journal, May 3, 1887. 



DERMATALGIA. 705 

The therapy of this affection is that of pruritus, already described, 
save where a parasite is recognized as the efficient cause, as in cases 
of scabies. 

The prognosis is favorable, though the disease is at times intract- 
able, persisting or recurring with repeated thermometric variations 
till the warm season is at hand. 



[B.] Dermatalgia. 

In this morbid state the integument becomes the seat of painful 
sensations, which may or may not be associated with a hyperes- 
thetic condition. This disorder is much more frequently symptomatic 
than idiopathic, and partial rather than general, being in the larger 
number of cases a local expression of some disease of the nervous 
centres or tracts. It is observed usually in middle life, and in 
women more than men. Its symptoms vary in severity and in char- 
acter. The pain is differently described as comparable to that pro- 
duced by friction, incision, penetration, contusion, or burning of the 
integument, as also to the passage over the part of streams of very 
hot or cold water, or the electric current. With this there is com- 
monly associated an undue sensitiveness to contact with foreign 
bodies. The skin presents no objective signs of disease. The dis- 
ordered sensations may be limited to the scalp, the region of the 
spine, or the palmar and plantar surfaces. In the latter situation it 
is often significant of some obscurely developed systemic disease, 
such as syphilis, rheumatism, or locomotor ataxia. In a middle-aged 
woman, lately under my charge, a persistent dermatalgia of the inter- 
scapular region was associated with confirmed gastric dyspepsia. In 
other cases the disorder is dependent upon disturbance of the uterine 
function. It is occasionally observed as one of the rare signals of 
the occurrence of the menopause. 

It is to be noted that the severe dermatalgia associated with dis- 
orders of the uterus in women, is occasionally succeeded by a cuta- 
neous lesion. In a middle-aged dysmenorrhceic patient under my 
charge, a pea-sized hemorrhagic bulla appeared over the forehead 
after several weeks of frontal suffering. Buck, 1 also, reports derma- 
talgia of the brow and wrists in a young woman who had frequently 
miscarried, followed by recurrent formation of a vesicle which accom- 
plished its career of rupture, crusting, and erosion, in a stadium of 
from five to seven days. 

The disease is to be differentiated from pruritus and hyperesthesia 
of the skin, as also from the affections of deeper parts, muscular, 
nervous, aponeurotic, and visceral. Severe pain, limited strictly to 
the skin of the lumbar region, with hyperesthesia, may precede the 
occurrence of perinephric abscess. 

The treatment is to be directed to the disorder, of which, in the 
great majority of cases, the dermatalgia is merely a local symptom. 

1 Phila. Med. and Surgical Reporter, Jan. 18, 1881, p. 677. 
45 



706 DISEASES OF THE SKIN. 

Quinine, the salicylates, iron, arsenic, and the phosphide of zinc are 
often indicated. Temporary relief, may, however, be afforded by the 
local application of the rubber bag filled with very hot or very cold 
water ; sometimes by an alternation of the two, each for a few 
moments at a time. Sponging of the part with very hot water is 
also useful, continued for longer periods, and followed by swathing 
in cotton-batting covered with the Lister protective. The anodynes 
may also be used topically with advantage ; especially cocaine or the 
oils, combined with opium, aconite, belladonna, and stramonium. 
In some cases relief is had by painting the parts with Squibb's 
oleate of mercury and morphia, a preparation particularly well 
adapted to meet the indications presented. The skin should gen- 
erally, in the interval of application, be protected by a dusting 
powder ; and the clothing worn next the skin be of an unirritating 
character. Care should be taken in dermatalgias limited to the 
trunk of women, lest the corsets be responsible for the mischief. 
The prognosis depends upon the nature of the cause of the abnormal 
sensations. In general it may be said that these cases are less per- 
sistent and annoying than those of confirmed cutaneous pruritus 
with melancholia. 

Anaesthesia. 

Gr., a, privative ; alo-&i?oig, sensibility. 

In this condition there is total or partial diminution of sensi- 
bility, with and without structural alteration of the skin. As in the 
affection just described, the disorder may be either idiopathic or 
symptomatic, general or partial, unilateral or bilateral, central or 
peripheral, and in varying grades of severity. Illustrations of the 
disease are furnished in the anaesthetic patches of leprosy, which may 
and may not exhibit textural skin changes, the disorder resulting 
from involvement of the nerves. Other diseases and conditions may 
be accompanied by partial or total loss of cutaneous sensibility, 
including centric and eccentric paralyses ; syphilitic, hysterical, and 
ataxic disorders ; partial or complete anaesthesia of artificial produc- 
tion ; the several toxic narcoses ; traumatism of nerves by pressure, 
wound, or contusion ; the local anaesthesia induced by cold, frigorific 
mixtures, and substances capable of benumbing the sensitiveness of 
the skin ; coma, of whatever origin ; and a number of idiopathic 
cutaneous disorders, including several of the atrophies, scleroderma, 
and morphoea. 

A curious divorce occasionally obtains between the elements which 
together constitute the compound sensory impression derived from 
the touch. The recognition of pain, of degrees of temperature, as 
also of the form, size, density, distance, weight, resistance, and other 
properties of foreign bodies, is accomplished largely by the sensory 
nerves ; and the power to appreciate one or several of these objective 
qualities may be in different degrees impaired. In this respect 
several forms of what, for want of a better term, may be named 



NEUROSES. 707 

cutaneous anaesthesia, are comparable to the conditions recognized in 
color-blindness. Thus, in some cases, there is appreciation of heat, 
but not of cold; of form, and not of weight; of pain, and not of 
objective qualities ; and the reverse. A curious illustration of this 
occurred in the person of a leper under my observation, whose hands 
were in all parts quite sensitive to the prick of a lancet and to contact 
with heated substances ; who vet exposed them for hours, without 
protection, to an atmospheric temperature of ten degrees below zero, 
without becoming aware of even slight discomfort. 

The neuroses described above are those of sensibility. Unques- 
tionably there are, beside these, a number of cutaneous affections 
popularly termed neuroses, which require mention in this connection. 
Unfortunately, in the present state of science, it is not certainly 
determined to what special class these affections should be definitely 
and permanently assigned. Some of them have already been 
described in these pages. In what follows there is attempted a 
schematic classification of the symptoms displayed in all, without 
attempting to discriminate between the parts severally played in each 
by nerve, vessel, and tissue. 

Vasomotor and Trophic Neuroses. 

Under the first of these titles, Schwimmer discusses erythema mul- 
tiforme, herpes iris, erythema nodosum, urticaria, and the medicinal 
erythemata ; under the second, prurigo and herpes (simplex and 
zoster). 

It is, however, to phenomena of a different character that in these 
pages attention is directed by these terms. These symptoms are, for 
the most part, symmetrical in distribution, and largely limited to the 
hands and feet, though in some instances, with or without implica- 
tion of these organs, other parts are invaded, most often the mouth, 
next the scalp, lastly the trunk. The four groups named below are 
readily recognized. 

In the first group the symptoms are functional chiefly, invading 
the feet alone, or the hands alone, or both the hands and feet, the 
symptoms predominating either in the one or the other. These are 
symmetrical hyperidrosis, anidrosis, bromidrosis; coldness of the 
organs, and symmetrical asphyxia (" dying " of the hands or feet, 
when immersed in cold water, digiti mortui). With the local phe- 
nomena may occur sudden attacks of faintness or giddiness ; a 
pulse ranging from very slow to very rapid action, and rheumatoid 
pains. Many of these symptoms are associated with those next 
described. 

In a second and larger group may be collected the symmetrical 
structural changes in the skin and its appendages without destructive 
degeneration, cutaneous or subcutaneous in situation. With these 
may be associated the blueness, coldness, or wetness of the organs, 
referred to above. One or several, usually all, of the nails may be 
here involved, these appendages becoming rough, dry, lustreless, 



708 DISEASES OF THE SKIN. 

friable, or gryphotic. They are usually tilted away anteriorly from 
their nail-beds by a corneous deposit visible beneath the free border. 
Here, also, may be enumerated, symmetrically arranged, livid or 
reddish blotches ; erythematous, vesicular, and scaling patches ; local- 
ized hypertrichoses and alopecias [of the legs chiefly] ; tyloses of 
palms and soles [in cases, with recurrent slough of the callosity] ; and 
local anaesthesia?. The Bleeding Stigmata which attracted the 
attention of the French and Belgian authorities in the years 
1873-1875 belong to the same category, as also the " Glossy 
Fingers " of Paget [q. v.]. 

In a third group may be placed the phenomena of Raynaud's 
disease, the cases of symmetrical ulceration and gangrene, and the 
other ulcerative and degenerating lesions, not necessarily fatal, in- 
cluding the " perforating ulcer of the foot " [malum perforans pedis] 
[q. v.]. Here are classed the cases described by Atkinson as " mul- 
tiple cutaneous ulceration," and the well-known cases of Eichoff, 
Boeck, Simon, Weiss, and Hutchinson. 

Leloir and Dejerine presented a case of this character at a recent 
meeting of the Societe de Biologie, in Paris. A young girl, of a 
family, several members of which were affected with nervous diseases, 
had, without any apparent cause, several patches of superficial 
gangrene develop on the cheeks; the small eschars soon separated, 
leaving a linear cicatrix, which gradually became transformed into 
cheloid elevations. The first happened three years before, and during 
this period she had suffered from several similar lesions on the trunk 
and arms. They began on the skin, by a sensation of pricking, with 
slight redness and notable diminution of sensibility at this point; in 
nine hours a white patch, not preceded by phlyctenule, formed and un- 
derwent after a short time superficial gangrene. Later the spot became 
brownish, detached at the edges, and was finally eliminated, leaving 
an ulcer and a cicatrix, the anaesthesia which existed around the part 
finally disappearing. 

In a fourth and final group may be set the cases which end fatally, 
in consequence of an apparently lethal tendency of the disease from 
the first. Here may be cited Hutchinson's "Form of Inflammation 
of the Lips and Mouth, which sometimes ends fatally, and is usually 
attended by some Disease of the Skin;" and a list of affections with 
cutaneous symptoms chiefly studied by neurologists, including the 
"pied iabetique" of Charcot; cases of posterior spinal sclerosis; and 
others of syphilitic, tuberculous, and rheumatic disease of the cord and 
meninges. 1 

The pathology of many of these disorders is clear, changes in the 
central and peripheral nervous tracts having been found sufficient to 
account for the phenomena (absence of axis-cylinder ; thickening of 
neurilemma; increase of endoneurium). In other cases, no lesions of 
the nerves have been recognized, and authors have not been wanting 

1 See the author's paper on " Symmetrical Hand and Foot Disease," read before the American 
Dermatological Association, August 31, 1887. 



MYXCEDEMA. 709 

who regarded some of the disorders named above as " purely local " 
in character. 1 

Myxoedema. 

Gr., (ivl-a, humor ; oldecj, to swell. 

(Cretinoid (Edema. Fr., Cachexie pachydermique.) 

Myxoedema is a disease chiefly of women, characterized by a constitutional cachexia, 
which usually results in the production of a cretinoid state, and is accompanied 
by a characteristic pachydermia. 

This disorder was first described by Sir Wm. Gall, 2 in 1873 ; and 
it has since been often observed, both abroad arid in this country, by 
competent observers, including Ord, 3 Mahomed, 4 Hadden, 5 Stokes, 6 
Hammond, Horsley, aud Ballet. For thirteeu cases reported iu this 
country, the reader is referred to an interresting report bv Dr. A. B. 
Ball, of New York. 7 

1 The subjoined bibliography is appended in view of the uncertainty respecting the proper 
distinction to be established with respect to several of the disorders named above : 

Atkinson. Amer. Journ. Med. Sciences, 1884, p. 57. 

Atkin, Charles. British Med. Journal, July 24, 1886. 

Anderson. Mc Call. Treatise on Diseases of Skin. London, 1887. 

Baker, Morrant. Clin. Soc. Trans., vol. xviii. 

Bouchard. Gaz. des Hopit., No. 112, 1884. 

Boeck, Csesar. Viertelj. f. Derm. u. Syph., 18«1. 

Ball and Thibierge. Lancet, Oct. 21, 1882. Report to Int. Med. Congress. 

Brehier. These de Paris, 1874, 

Biggs. Lancet, 1876, vol. vii. p. 735. 

Billroth. Wien. med. Wochen., No. 23, 1878. 

Callander. Clinical Society's Trans., April 12, 1878. 

Duplay. Arch. gen. de Med., 1876, p. 346. 

Dejerine. Le Progres Med., 1882, No. 6. 

et Leloir Arch. gen. de Phys., 1881, p. 1011. 

Eichoff. Deutsche med. Woch., No 34, 1880. 

Elliot. Journ. of Cutan. and Gen.-urin. Dis., May and June, 1887. 

Erichsen. Surgerv, 1879. 

Esllander. Arch. f. klin. Chir., 1870, xii. p. 453. 

Flynn. N. Y. Med. Record, March 28, 1885. 

Foulquier. These de Paris, 1874. 

Hamilton, A. McLane. N. Y. Med. Journ., Oct. 1874. 

Hastreifer. Wiener med. Presse, 1882. No. 33. 

Hutchinson, J. British Med. Journ., June 18, 1887. 

. British Med. Journ., May 7, 1887. 

Heusner. Deutsch. med. Woch.. No. 16, 1885. 

Jones, S. Path. Soc. Trans., No. 7, 1876. 

Kirmisson. Arch. gen. de Med., January, 1885. 

Michaud. Lyon Med., January, 1876. 

Miles Amer. Journ. of the Med. Sci., October, 1878. 

Mitchell. Amer. Journ. of the Med. Sci., July, 1878 

Mougeot. These de Paris, 1867. 

Nelaton. Gaz. des. Hopit., January 10, 1852 

Ogston. Lancet, 1878, p. 13. 

Pitres et Vaillard. Arch. de. Phys., Feb. 15, 1885, p. 209. 

Petit et Verneuil. Rev. de Chirurg., No. 19, 1883. 

Raynaud. Arch. gen. de Paris, 1874. 

These de Paris, No. 28, 1862. 

Simon, Oscar. Breslau. Aerztliche Zeitschrift, No. 1, 1879. 

Schwimmer. Art. Malum perforans Pedis— Ziemssen's Handbook of Diseases of Skin. 

Savory and Butlin. Med. -Chir. Trans., vol. lxii., 1879 (illustrated). 

Starr. Journ. of Nervous and Mental Dis., February, 1886. 

Terillon. Revue Med., 1886. Report made to the Surgical Society of Paris. 

Tilden. Journ. of Cutan. and Vener. Dis., October, 1886. 

Treves, Frederick. Lancet, March 29, 1884, p. 950. 

Warren. Boston Med. and Surg. Journ., No. 13, 1879. 

Weiss. Wiener Klinik, 1878. 

Wilks. Surgery of the Foot, p. 57. 

2 Trans. Clin. Soc. London, 1874, vii. p. 170. 3 Med.-Chir. Trans., 1878, v. p. 57. 
4 London Lancet, 1881. 5 Brain, 1882, 4. 

6 N. Y. Med. Record, July 10, 1886. ' British Med. Journ., Oct. 16, 1886. 



710 DISEASES OF THE SKIN. 

Symptoms. — The disease occurs in both acute and chronic mani- 
festations, usually after the fortieth year, and in women more often 
than in men. It may, however, be first noticed in childhood. 

There is first observed a persistent and remediless anaemia, gradu- 
ally succeeded by mental hebetude, sluggishness of bodily movements, 
and a characteristic change in the skin. The latter becomes dry, 
yellowish, waxy, translucent, thickened, firm, and refuses to pit on 
moderate pressure, the mucous membranes often participating in the 
morbid process. In the cheeks there is usually preceptible a brawny 
redness ; defined at times as a sharply circumscribed, pinkish flush 
extending quite to the lower lids, which may be, as in Bail's cases, 
wrinkled, boggy, and swollen. The eyes, for this reason, seem 
smaller than natural and more widely separated. In consequence 
of the swelling and immobility of the features, the facies is character- 
istic : the broad, thick nose ; swollen, pendulous, or even everted 
lips ; expressionless eyes : and leathery cheeks producing a mask-like 
impression upon the observer. The skin of the other regions of the 
body participates in these changes. The mucous membrane of the 
mouth (gums, palate, pharynx) becomes tumid and fungous. 

In the triangles at the side of the neck, and also at its back, are 
" bolsters " of fat. The hair of the head becomes harsh and scanty ; 
alopecia may be complete. Pigment alterations readily occur ; moles 
increase in size ; aud the general tint of the skin may vary from that 
of dry parchment to the hue of Addison's disease. The gait is 
waddling aud uncertain. The thyroid gland atrophies. Anaesthesia 
is of common occurrence. Tongue, uvula, and fauces are often so 
thickened and immobile as to make speech both slow and indistinct. 

Stokes reports ten cases of acute myxoedema following thyroid- 
ectomy. In these cases, beside the rapid occurrence of the symptoms 
enumerated above, there were convulsive seizures of an epileptiform 
character. The course of the disease is chronic, lasting for years and 
terminating usually in a state of marasmus with fatal issue. 

Etiology. — The cause of this disease is imperfectly understood, 
though its association with the abolition of the thyroid gland (after 
pathological chauge or ablation) is generally admitted. The influence 
of heredity is distinctly shown in cases reported by Ball, Ord, Saville, 
and Taylor. One hundred and one, of one hundred and twenty-one 
cases collected by Ball, occurred in women. The disease may affect 
children, but is more common in middle life. 

At the present date it is undetermined what relations, etiological 
or other, subsist between the members of an interesting group of 
maladies, all characterized by cutaneous changes or dystrophy of the 
appendages of the skin, and total or partial abolition of the functions 
of the thyroid gland. In this group are to be named not merely 
myxoedema, but also myxoedematous cretinism, acromegalia, and 
Graves's disease. These are denominated by some authors, the 
" Thyroid Cachexias." 

Pathology. — The disease seems to be due to the deposit of mucin, 
or " animal gum," in the meshes of the connective tissue. This 



PARASITIC AFFECTIONS. 711 

mucinoid degeDeration may involve the pneurnogastric, glosso- 
pharyngeal, great sympathetic, and other nerves. The psycho- 
cortical centres are unquestionably similarly involved. In the skin, 
the fibrillar of connective tissue multiply, their nuclei becoming large 
and distinct. The mucin-yielding cement substance between these 
fibrillar appears in large amounts in the interstitial spaces. In a 
post-mortem examination made by Ord, it was estimated that the 
skin contained fifty times the normal amount of mucin. 

Diagnosis. — Cases of myxcedema are readily distinguished from 
those of elephantiasis by the generalization of the symptoms, the 
nervous state of the patient, the fat deposits, and the condition of the 
thyroid gland. Acromegaly involves the bones ; in lepra, there are 
commonly anaesthetic symptoms or characteristic tubercles. 

The Treatment of myxcedema has hitherto sought amelioration of 
the symptoms by the employment of roborant and tonic measures ; 
alkaline and sulphur baths ; electricity aud massage. The later 
method of treatment, however, is by administration of thyroids. 1 
Whether the gland itself of the sheep, or the powder skilfully pre- 
pared by evaporation, or Vermehren's extract precipitated by alcohol, 
be employed, the results are satisfactory in so large a proportion of cases 
that the prognosis of this group of disorders promises to be, in the 
near future, very greatly improved. The headache, faintness, loss of 
weight, neuralgias, and even albuminuria, with other symptoms imme- 
diately following the employment of the thyroids in the methods 
named above, do not seem to have any adverse influence upon the 
remoter benefits received from the treatment. 



CLASS VIII. 

PARASITIC AFFECTIONS. 

The cutaneous disorders of this class possess many features in 
common with those already described. In them, as in others, are 
observed the hypersemic and exudative processes which result in 
surface lesions of similar type and career. They differ, however, 
from other affections of the integument, in that they are all induced 
by parasites of either vegetable or animal origin ; and are, as a con- 
sequence, commonly characterized by certain special features. They 
involve the skin and its appendages, their symptoms being at times 
displayed chiefly in the integument proper, and at others in one or 
more of the cutaneous appendages, according to the mode of propa- 
gation and attack, peculiar in each case to the parasite present. They 
are all in different degrees contagious ; and being induced by local 

1 See a valuable paper on this subject, " Feeding Thyroids in Myxcedema," by J. J. Putnam ; 
Amer. Journ. of the Med. Sciences, August, 1893. 



712 DISEASES OF THE SKIN. 

and tangible causes, are usually relieved by external treatment. 
Their importauce in cutaneous medicine rests not only upon the facts 
named above, but also upon the too general misconception regarding 
their nature, since there are many patients treated by internal 
remedies ingested vainly for long periods of time, who are yet 
suffering from parasitic disorders often remediable by very simple 
local measures. 

It should not be forgotten, however, that, distinct though these 
maladies be in an etiological sense, they are yet often practically 
commingled with others. Thus an eczematous scalp in a child may 
by accident become the habitat of lice ; and the eczema induced 
originally by the acarus scabiei may long persist after the destruction 
of the parasite. 

The term tinea, derived from a Latin word meaning a moth or 
worm, has by common consent been adopted as a generic designation 
of all the cutaneous disorders induced by the presence of vegetable 
organisms. 



1. Vegetable. 
Tinea Favosa. 

Lat., favus, a honeycomb. 

(Honeycomb Ringworm ; Porrigo Favosa ; Favus. Fr., Teigne 
faveuse; Ger., Erbgrind.) 

Statistical frequency in America, 0.286. 

Tinea Favosa is a contagious disease of the scalp, and less frequently of other 
portions of the surface of the body, characterized by pea- to coin-sized, 
sulphur-yellow, and umbilicated crusts, commonly traversed by hairs, and 
produced by the invasion of a vegetable organism, the achorion Schonleinii. 

Symptoms. — Favus affects chiefly the scalp, but also occurs upon 
the so-called non-hairy portions of the skin and upon the nails. In the 
former situation it is usually first recognized by the development of 
minute, sub-epidermic, yellowish or reddish puncta, visible through 
the translucent stratum corneum at the site of implantation of the 
hairs. A peripheral circle of delicate vesicles may surround these 
spots. Puncture with a needle usually gives exit to a puriform 
matter. In the course of a fortnight or more these develop into 
pea-sized and somewhat larger, friable, circular, and elevated crusts, 
having the yellowish tinge of the lemon or sulphur, and a concavo- 
convex shape, with the free concave face of the disk exposed. At 
the centre of the umbilication thus presented to the eye, one or 
several hairs usually make exit to the surface. The inferior surface 
of this disk, or scutulum, rests upon the scalp, which is either moist 
and deprived over a circumscribed area of its epidermis, or is smooth, 
dry, reddened, and tender. When the crust is removed by traction 






TINEA FAVOSA. 713 

upon the hairs or otherwise, a minute cup-shaped depression is left 
at the point where the lowest level of the favus crust was in intimate 
connection with the epidermis. 

The subsequent features of the crusts, the hairs, and the scalp, are 
subject to some variation. The first may acquire a brownish or 
greenish tinge by admixture with dirt or dried pus ; may coalesce 
(favus squamosus); or may, by gradual desiccation, exchange the 
yellowish hue for the dirty whitish shade of old mortar, a substance 
which they then resemble in dryness and friability. The hairs, 
invaded both in sheath and shaft, may lose their lustre ; become 
fragile ; appear as fractured relics of longer filaments ; be readily 
extracted from their follicles ; and be finally shed, leaving behind 
hair-sacs destined to fall into atrophy, and incapable of reproducing 
a pilary growth. The scalp may be first the seat of an extensive 
hypersemia or exudation going on to the formation of pus, when the 
fungus is a source of acute irritation in consequence of its active 
development. Later, when its destructive work may be said to have 
been accomplished, the scalp surface is bald, irregularly atrophied, or 
disfigured with minute circatrices, while here and there remain tufts 
of hair which have survived the attack. 

The lesions may be discrete or confluent, and vary in either case. 
Occasionally but a few small and ill-developed crusts form upon the 
surface. The entire scalp is not often covered with a confluent favus 
crust. The disease is usually chronic in its course. Untreated, it 
may undergo spontaneous involution after total destruction of all 
hairs and production of general follicular atrophy, but this is rare. 
It may last for fifteen or twenty years, and even longer. It is often 
accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching ; and, 
as a result, it is not rare to find the favus crusts torn and broken by 
the comb or the nails. 

The yellowish disks of the disease occur also in typical develop- 
ment, though more rarely, upon the surface of the face (including the 
bearded cheeks, lips, and chin), and upon the trunk and extremities. 
Dr. (xeorge Henry Fox, of New York, has photographed a patient's 
knee which is covered on its extensor aspect with favus crusts. 

When the nails are invaded, light or deep yellowish, circumscribed 
spots become visible through the nail structure, and by the extension 
of these, in consequence of the growth of the parasite, the nail-tissue 
may be thickened, irregularly split, laminated, separated from its 
matrix, or atrophied. The complication is rare, and supposed to be 
due to the transfer of the parasite from the scalp to the hands in the 
act of scratching. When it exists, the epidermis fringing the nail is 
usually also involved. 

Upon the so-called non-hairy portions of the body, favus occurs 
in the same forms as elsewhere, the localities being in the order of 
frequency those most exposed to the hands charged with the para- 
site, or to other sources of the disease, viz., the hands (chiefly the 
backs and nails), the upper and lower extremities, and the shoulders. 



714 DISEASES OF THE SKIN. 

It is a striking fact that favus may exist for years on the scalp with- 
out spreading elsewhere. At a recent clinic for practitioners in the 
city of Chicago, I lately exhibited five patients affected with the 
disease, all scalp cases, the eldest a male, twenty-five years of age, 
who had suffered from the disease for twenty years without occur- 
rence of the lesions elsewhere. 

' In favus of the bodily surface outside of the scalp, there is often 
a resemblance to ringworm in the production of circular patches 
with an active border made up of vesicles or papules, which may 
have a favus scutulum as a centre ; or several of these cups may be 
irregularly spread over circles of scaling patches. In these cases 
there is often an acuity of symptoms not observed in scalp cases and 
coincident gastro-intestinal symptoms of irritation, vomitings, etc., 
which Kundrat believes may originate in favus of the mucous sur- 
faces of the oesophagus and gastro-intestinal tract. 

Favus of the Nail (Favic Onychomycosis). One or several of 
the nails may be the seat of the fungus, and either the entire body of 
the nail or but a part of it. The lesions are maize-yellow points or 
macules where the substance of the organ is eroded, fissured, or split 
into striations, changes quite like those induced by other causes. The 
connections of the nail with the underlying nail-bed and nail-folds 
are loosened, wholly or in part, while the matrix itself still holds the 
nail firmly in position. 

Under the microscope minute collections of spores surrounded by 
branching mycelium of the achorion, are recognized in isolated 
points or in diffuse patches in epidermic scales scraped from the sur- 
face. The fungus never penetrates within the papillary layer, but 
ramifies to a varying extent in different cases in both the upper and 
lower portions of the rete. 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice ; also to that of the urine of cats. It should not be 
confounded with the peculiarly disgusting odor of many neglected 
scalps affected with lice or covered with pustules and filth. The 
disease not infrequently coexists with other cutaneous, parasitic and 
non-parasitic diseases : as, for example, seborrhcea, eczema, and tinea 
tonsurans. 

Etiology. — Favus is always produced by the presence and develop- 
ment of the vegetable organism which is named after its discoverer, 
the achorion Schonleinii. It is a contagious disease, simply because 
the parasite which produces it is capable of transmission from man 
to man, as also from animals to man, and vice versa. It is often con- 
veyed to man from mice, cats, dogs, rabbits, fowls, and ponies ; but 
when derived from the lower animals, is most often transmitted from 
mice to cats and from cats to man. It shares with other diseases 
originating from vegetable parasites, the peculiarity of attacking cer- 
tain individuals specially predisposed to such invasion, either by reason 
of physical peculiarities of organization, or accidental and fortuitous 



TINEA FAVOSA. 715 

circumstances. It is most common from infancy to the thirtieth year 
of life. It is rare in the United States, Austria, and England ; and 
more common in France, Scotland, and Poland. It is said by Ber- 
geron 1 to be a disease of the country, while tinea trichophytina pre- 
vails in the cities. This statement is certainly corroborated by the 
author's experience. Favus is more common in public than in pri- 
vate practice, and the larger number of clinical patieuts with favus 
come to the city from the country. 

Evidences of contagion are exhibited in those cases where several 
members of the same household are affected with the disease ; but in 
other cases the absence of a history of contagion after exposure indi- 
cates the relative difficulty experienced in propagating the conta- 
gious element in the case of favus. Thus one individual, exposed 
among a dozen who are diseased, will fail to exhibit any favus crusts; 
and the latter by no means form in all situations of the same body 
where the fungus can be discovered by the microscope. Aubert, 2 
indeed, presents an argument in favor of the production of the dis- 
ease by traumatism, the resulting wounds, excoriations, etc., becom- 
ing by accident the seat of the disease. It is not very rarely discovered 
under poultices and fomentations. 

Occasionally favus occurs in special localities with such develop- 
ment among men and the inferior animals as to constitute an 
epidemic. Girard 3 reports thus the simultaneous existence of the 
disease among sixteen cows and four children in the village of 
Nantoin, in France. It is propagated also upon the skin of rats 
and mice, from which it is transmitted to man, often through the 
medium of the domesticated cat and dog. 

Pathology. — Under the microscope, the fungus is readily recognized 
in the root-sheaths, the bulbs, and the shafts of the hairy filaments 
near the scalp. At a distance of about two inches from the bulb it 
ceases to appear in the tissue of the hair. It is also seen upon the 
free surface of the skin. The favus crust, softened by the addition 
of a little water or dilute liquor potassse, may be placed upon the 
slide of the microscope without other preparation for its study. 
Under a good one-fourth or one-sixth of an inch objective, the vege- 
tation is seen to be composed of intricate masses of mycelium and 
spores in great quantity. 

Quincke (Monatsheft f. prakt. Dermat., 1889, t. viii. p. 49) has 
attempted to distinguish between three varieties of the favus fungus, 
designated respectively as a, (3, and y. Elsenberg, Krai, Pick, Unna, 
and others have, however, arrived at different conclusions upon the 
same subject, some recognizing but two of Quincke's forms ; others, 
two separate forms not corresponding to the a, (3, or y forms of 
Quincke ; and still others yet different forms, corresponding to none 
of those previously described. I have taken pains to make special 
observations upon the distinctions suggested above, and as a result, 

1 Etude sur la Geographie et la Prophylaxie des Teignes. Paris, 1865. 

2 Role de traumatism dans l'Etiologie de la Teigne faveuse (Annal. de Derm, et de Svph., 
April, 1881). 

3 Lyon Med , August 18, 1880, p. 547. 



716 



DISEASES OF THE SKIN. 



am in accordance with the majority of observers on this point, that 
there is but one achorion fungus, displaying itself in several forms 
both under the microscope and clinically, the differences being due to 
accidental influences (varying amount of heat, moisture, and friction 
in the involved surface). 

The threads of the fungus usually preponderate, and appear as 
narrow, flattened, ramifying, short or elongated, linear cells or tubes. 
These may be simple and empty, or be divided more or less regularly 
by transverse partition walls, transforming the longer and simple into 
shorter and compound cells. The latter often contain in their cavities 
sporules clinging to either side, in which case the mycelial threads are 
termed sporophores. This is the vegetative part of the cryptogamous 
fungus ; and it develops by multiple subdivisions into cells, which 

Fig. 91. 




Achorion Schonleinii. a, spores ; b, e, sporophores. (After Cornil and Ranvier 



may also themselves similarly increase in number, or by the pro- 
duction, at the terminal extremities of certain of the mycelial threads, 
of spores or conidia. The latter are encapsulated, or strung together 
like the beads upon a necklace, and appear as round, oval -shaped, 
angular, or very irregularly contoured bodies, often provided with 
partition walls like mycelium, constituting thus compound cells. 
At the same time, an amorphous granular matter can usually be dis- 
tinguished in the mass of the fungus. The hyphse vary in width from 
0.0023 to 0.0030 mm.; and the spores, from 0.0023 to 0.0052 mm. 

Examination of the invaded scalp reveals, according to Unna, 1 the 
presence of the fungus at the lower border of the upper three-fourths 
of the root-sheaths, where chains of conidia appear among the histo- 
logical elements. His view is that the cuticle of the hair offers a 
relative resistance to the growth of the vegetation ; that the latter 
first penetrates the stratum corneum and the follicular orifice, and 
then stretches, upon the one hand, into the cortex and medulla, 
through the cuticle of the hair ; and, on the other, passes to the inner 
root- sheaths, the outer remaining always intact. In the epidermis, 

1 Viertelj. f. Derm. u. Syph., vii. p. 170. 



TINEA FAVOSA. 717 

the fungus has a predilection for the tissues between the superficial 
and deep portions of the stratum corneurn, stopping as if before a 
wall, at the living protoplasmic masses of the rete. The superior 
pars vascularis of the corium exhibits enlarged vessels surrounded 
by inflammatory elements. 

"When the nail is involved, the parasite may be recognized in the 
debris produced by scraping the nail-substance ; often also in the 
epidermis bordering the nail. It exhibits here the same microscopical 
features as upon the scalp, though, in consequence of the denser 
structure of the nail-substance, its vegetation is usually less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, often aided 
by a history of contagion, and the peculiar odor emanating from the 
scalp. The secondary effects upon the hairs, hair- follicles, and skin, 
are also, when present, significaut. Dr. White, of Boston, in a valu- 
able essay on the " Vegetable Parasites, and the Diseases caused by 
their Growth upon Man/' calls attention to the stage in which the 
disease is likely to be mistaken for ringworm. It exists before the 
formation of the crust, and may be characterized by hyperemia, 
vesiculation, or papulation, often unnoticed beneath the hairs of the 
scalp. 

The recognition of the disease by the microscope is, however, the 
most certain method of establishing a diagnosis ; and this is readily 
accomplished. Aubert, 1 in the absence of the clinical features named 
above, lays stress upon an intense redness of the scalp where the hairs 
have been cut and the crusts removed, this color being limited to the 
portions attacked by the disease. The hairs, also, as a result of the 
disintegration of their elements, are infiltrated by air, and look 
opaque and black by transmitted light. By reflected light, these 
appear polished and stratified. It should not be forgotten that, in 
exceptional cases, favus crusts coexist upon the body with other dis- 
eases of prior or subsequent origin, as indicated above. The disease 
should not be confounded with seborrhcea, pustular eczema, or 
psoriasis of the scalp, none of which exhibits the special features of 
a parasitic fungus. 

Treatment. — The first indication in the treatment of favus is to 
cleanse the surface thoroughly from all favus and other crusts and 
scales which may be present. For this purpose the scalp (if this be, 
for example, the affected part) is first shorn of its hair with the 
scissors, and then thoroughly soaked in olive, cod-liver, or other oil, 
or glycerin. After this, all the crusts are scraped away with a spatula, 
and the scalp washed clean with hot water and soap, the spirit of green 
soap being here preferably used. The scalp should be then again 
anointed with oil, or covered with an emollient poultice. Once 
thoroughly cleansed by repeated soakings in oil and ablutions, it is 
necessary to resort either to the topical employment of parasiticides 
(agents capable of destroying the fungus) or epilation (the extraction 

1 Annal. de Derm, et de Syph., 2e. ser., 11, p. 3-4. 



718 



DISEASES OF THE SKIN. 



of the hairs). Often both measures are required. Without further 
treatment, the scalp, however completely freed from all evidences of 
the disease, will not fail to show fresh favus crusts in a fortnight or 
somewhat longer time. 

Epilation is practised by the aid of epilating forceps. These should 
be constructed with an easy spring that will not tire the fingers of the 
operator ; with blades that are sufficiently broad to grasp a few hairs 
at once ; and with smooth, or slightly serrated faces of the blades, as 
otherwise the hair is liable to fracture in the grasp of the instrument. 
The surface to be operated upon should be previously anointed with 
vaseline or olive oil, and the hairs be entirely removed, a sufficient 
number, covering a definite space, upon successive days. 

The tediousness of this process has led to several devices by which 
it is sought to do away with its necessity. Originally the " calotte " 
was employed for the removal of the hairs. It was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk motion of the hand, 
the hairs which adhered were forcibly uprooted en masse; those 
remaining being adherent in their sacs in consequence of the fact 
that they had not been invaded by the fungus. As a substitute for 
this somewhat brutal procedure, Bulkley l has employed adhesive 
masses, or sticks, which can be melted and made to adhere at once to 
large numbers of the hairs. When cold they can be withdrawn from 
the surface with the hairs attached. These sticks are from two to 
three inches in length, and from one-fourth to three-fourths of an inch 
in diameter. The hair is first clipped so as to be about one-eighth of 
an inch in length. The end of the stick is then heated in an alcoholic 
flame, and quickly placed upon the scalp. It is thus left in place till 
quite cold, and removed by bending it over and drawing upon the 
hairs successively with slight rotation. When free, it is found 
thickly set with the extracted filaments, which may be burned off in 
the alcohol flame, thus destroying both the hairs and any adherent 
fungous masses. The stick is then carefully wiped clean with paper, 
after which it is again ready for use. The formula for the mass of 
which these sticks are composed is as follows : 



H . Cerse flavse 


3iiJ5 


12 


Laccse in tubulis 


3 iv ; 


16 


Resinse 


3 y j; 


24 


Picis Burgundicse 


3 x j; 


44 


Gummi dammar. 


3jss; 


48 



M. 

The parasiticides in greatest favor are: corrosive sublimate in solu- 
tion in the strength of one-half to four grains (0.033-0.266) to the 
ounce (32.); sulphite of sodium in saturated solution ; pure or diluted 
sulphurous acid; spirit of green soap; chrysarobin, pyrogallol, tar, 
croton oil, boric, carbolic, and salicylic acids; petroleum, chloroform, 
ether, creasote, and the oil of cloves. Ointments are also useful con- 
taining mercury (citrine ointment, yellow sulphate or white precipi- 



1881. 



Favus and its Treatment by a New Method of Depilation. Arch, of Derm., vii. No. 2, April, 



TINEA FAVOSA. 719 

tate), naphthol, benzol, thymol, sulphur, pyrogallol, salicylic, and 
carbolic acids. Chrysarobin is very effectual in an ointment, though, 
objectionable on account of the staining of the scalp, and, almost 
inevitably, of the face also. Lenzberg x generates sulphur fumes in a 
dish of red-hot coals attached to a frame, made of wood or paste- 
board, close to the head of the patient. By means of a paper cap, 
the fumes are collected and retained for from five to ten minutes, in 
contact with the patient's hair. During ten years' trial of this plan, 
he has never been compelled to resort to epilation. 

One or more of the methods may be needed, either at the same time 
or by repetition or alternation, till the fungus is entirely destroyed, the 
requisite period usually extending over three months. Treatment 
should then be discontinued, in order to test the result by observation. 
If, in the course of a fortnight or more, a relapse occurs, the treat- 
ment is to be promptly renewed. Upon the non-hairy portions of 
the body, parasiticides thoroughly applied usually procure a radical 
relief. When the nail is involved, it should be cut short and care- 
fully scraped or softened by repeated applications of a strongly 
alkaline lotion, after which a parasiticide may be employed in oint- 
ment or lotion. 

In general, it may be remarked that patients long affected with 
rebellious favus may need a roborant course of treatment and nutri- 
tious diet. Cleanliness here, as in all the parasitic disorders, is 
essentially important. As adjuvants in the treatment of the scalp 
and nails, it is well to remember that continuous applications of a 
parasiticide are aided by caps or cots of impermeable material, super- 
imposed upon rags saturated with the medicament employed. 

Prognosis. — The prognosis is generally favorable to the ultimate 
termination of the disease in all cases ; for even the most rebellious 
and untreated forms are relieved when the hair-follicles atrophy. 
Upon the non-hairy portions of the body, the disorder is rarely 
severe if promptly and efficiently treated. Upon the scalp, the prog- 
nosis is proportioned to the extent, severity, and period of prior 
invasion of the disease. Early and vigorous treatment of the scalp 
in healthy children is usually followed by satisfactory results. In 
long-neglected subjects of the disorder, the result may be a remedi- 
less and characteristic baldness, the affected surface being provided 
with scanty wisps of short, stunted, and uncolored hairs. Neglect, 
filth, and systemic malnutrition are the most unfavorable elements 
in any case. 

i Der prakt. Am.. Feb. 1881. 



720 DISEASES OF THE SKIN. 

Tinea Trichophytina. 

Gr., dpi!;, hair ; <pvr6v, a vegetation. 

(Ringworm.) 

Statistical frequency in America, 1.85. 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and beard, as also of the non-hairy portions of the body. In each 
case it is produced by the presence of the same vegetable fungus, the 
trichophyton. Inasmuch, however, as each of these regions of the 
body, when the parasite is present, displays lesions which are more or 
less peculiar to itself, it is usual to consider each separately. Ring- 
worm of the body is hence designated, Tinea Circinata ; of the 
scalp, Tinea Tonsurans ; of the beard, Tinea Sycosis. 

[A.] Tinea Circinata. 

(Herpes Tonsurans ; Ringworm of the Body. Fr., Herpes circine ; 

Trichophytie.) 

Statistical frequency in America, 0.569. 

Tinea Circinata is a contagious disease of the skin, characterized by macular, 
vesicular, papular, squamous, and rarely pustular lesions, having usually 
a clearly defined, circular outline, and induced by the presence of the tricho- 
phyton 

Symptoms. — Ringworm of the body displays different symptoms, 
according to the temperature in which the vegetation flourishes, and 
the various external irritants to which the skin, where it has once 
been implanted, is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or several pea- to large coin-sized, circumscribed, reddish cir- 
cles, usually paling under pressure, often at the general level of the 
integument, occasionally slightly raised above it, forming then a flat- 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye quite unaffected, transforming the patch to an annular 
lesion, from which circumstance it originally received the name " ring- 
worm." It develops within certain limits, rarely exceeding five or 
six inches in diameter, by peripheral extension ; and is usually 
characterized at the outer border by slight, whitish, furfuraceous des- 
quamation. This form of lesion is usually seen upon exposed 
surfaces of the body where there is less heat, moisture, and friction, 
than upon others, as, for example, the forehead and neck in moderate 
atmospheric temperatures. From it may be developed the other forms 
described below. The disease may recur within the peripheral 
border ; in this way occasionally two, three, and more concentric 
riugs or parallel bands of crescentic outline may be visible in a 
single patch of disease. The subjective sensations are a trifling degree 



TINEA TRICHOPHYTIN A. 721 

of itching or burning. Should these rings extend to the beard or 
scalp the circinate may coexist with the other varieties of the disease. 

The vesicular lesions of ringworm appear as such at the onset, or 
rise from the macular lesions described above. In the former case, 
pin-point sized, transitory, and superficial vesicles or vesico-papules 
spring from a central point or focus, or speedily shrivel till they are 
represented merely by minute, whitish, branny scales. To these 
others succeed, always at the periphery, and to these again yet others, 
the rosy or reddened base on which they rest being sometimes slightly 
in advance toward the outlying skin. The enlarging circlets of dis- 
ease proceed in their course to an evolution quite similar to that 
observed in the macular forms. The difference, due chiefly to a some- 
what more active development of the fungus, is noted not merely in 
the type of the lesion, but in the slightly exaggerated pruritic sensa- 
tions which are awakened. Rarely, both of the forms described are 
presented with acute symptoms and extensive development, in multiple 
patches spreading over the face, neck, trunk, and extremities, accom- 
panied by a slight febrile movement and moderate tumefaction of the 
affected surfaces. As a rule, the eruption is trifliug ; and may, indeed, 
be limited to a single ring, or very few circlets about the neck, termi- 
nating in the branny desquamation described ; but in the severer 
forms the evolution of the disease may persist for months; and crusts 
form, whose fall leaves annular pigmentations of temporary duration. 

The papular and rare pustular forms of the disease observe the 
same peculiarities with respect to the clearing of the centre, the 
annular appearance of the advancing area of involvement, and the 
production finally of scales and crusts. They represent, however, 
either a much more luxuriant vegetation of the fungus, or the irrita- 
tion of the affected part by friction and heat, or, what is probable, 
the co-operation of the two. They are, hence, most commonly 
observed upon the back, the belly, the inter- and infra-mammary 
regions, and the internal faces of the thighs and arms, in which 
localities they occasionally occur with chronic manifestations. The 
papules are light or dull reddish, pin-head and larger, solid eleva- 
tions, roundish, oval-shaped, irregular, or confluent, forming event- 
ually bean- to coin-sized, raised disks with a pale, exfoliating, or 
actively inflamed centre, the so-called "nummular" or "Discoid 
Trichophytic Erythema" of French authors. The itching is some- 
times in these forms severe ; and the process may display central 
recrudescence, as noted above. Pustules found at the periphery have 
the size and distribution of the other lesions described. They rep- 
resent merely an aggravated exudative process awakened by the fun- 
gus, and the scratching incident to the pruritic sensations excited. 

Partly because of the controversy which the subject has aroused, 
special attention was once directed to the disease which Hebra was 
first to name, Eczema Marginatum. It is most marked upon 
the portions of the body which come in contact with the saddle when 
a rider is mounted on a horse — that is, the perineum and the inner 
faces of the thighs, the region well marked by the reinforcing patch 

46 



722 DISEASES OF THE SKIN. 

in the trousers of the cavalryman. The disease, as encountered here, 
is termed Tinea Trichophytina Cruris, and occurs in both 
sexes. It is characterized by extensive exudation, in bright or lurid 
patches, with a very distinctly denned, raised border, showing a 
sharp contrast with the healthy skin beyond, from which peculiarity 
it has its name. It may extend laterally over the groins, upward 
over the pubes, and backward over the sacrum, being generally 
denned at the periphery by a crescentic outline. The centre may be 
paler and less involved, or actively irritated, while the periphery still 
extends in one or more annular festoons down the inside of the thigh 
or upward over the regions indicated. The itching is severe ; the 
course of the disease obstinate, persistent, and subject, in a remark- 
able degree, to relapse in the same locality. The fungus is always 
present, whether occurring as a cause or epiphenomenon of the dis- 
order. It was rightly named by Hebra; and deserves special recog- 
nition under whatever title it may be classified. It is a true eczema, 
with special features, complicated by the development of the tricho- 
phyton, and, as is now well known, often by other representatives of 
the " dermatological flora. 77 It is aggravated by heat, the moisture 
of the sweat, and the friction of apposed surfaces of the skin in con- 
tact with each other and the clothing. After detecting the fungus 
in scales scraped from the surfaces thus involved, one is always 
in such case impressed with the characteristic clinical peculiarities 
of the disease. It is usually of symmetrical distribution, due to the 
circumstances of its development, and in this respect differs from 
the other manifestations of the disease. 

When the nails are affected, the disease is termed Tinea Tricho- 
phytina Unguium, or Onychomycosis. These appendages of the 
skin then become friable, opaque, and lamellated ; and are clinically 
indistinguishable from nails secondarily changed in eczema, psoriasis, 
and similar disorders of the integument. One or several of the 
nails of both feet and hands may be affected. When all the nails 
of both extremities are involved, the disease is rarely of parasitic 
origin. The microscope is requisite for establishing the diagnosis in 
such cases, the parasite being detected in the fragments procured by 
scraping the nail. 

Etiology. — The disease is caused by the presence of the parasitic 
though the latter may be an accident of other cutaneous disorders. 
The trichophyton was first discovered by Gruby, in 1844; though 
Malmsten, whose name is often associated with that of the fungus, 
became identified with its recognition, by his observations during the 
succeeding year. As a contagious disease, it ranks higher in the 
scale than favus, being much more readily communicated ; and, as a 
result, much more common. Occurring upon the non-hairy portions 
of the body, it is often spontaneously removed by the desquamative 
process which it excites in the skin. 

Though the fungus is the essential cause of the disease, its devel- 
opment is greatly favored or retarded by external influences. Atten- 
tion has been already called to its luxuriance under the influence of 



TINEA TRICHOPHYTINA. 



723 



heat and moisture. It is, hence, much more severe and rebellious to 
treatment in tropical countries. It occasionally occurs in epidemic 
forms. Thus Gerlier 1 gives the details of such an epidemic in 
Ferney- Voltaire, where twenty-six cases came under his observation. 
In some of these the lesions were pustular ; in others, tuberculo- 
pustular. Aggravated forms of the disease seem also to originate in 
the lower animals. I have seen certain mild types of ringworm 
transmitted to man from cats and dogs. Gerlier concludes that the 
most rebellious and persistent forms are derived from the horse ; 



Fig. 92. 




Epidermis invaded by trichophyton, a, inferior portion of the stratum corneum ; b, superior 
portion of the rete. Both exhibit long mycelial threads, with a few ramifications and a 
small number of spores. (After Kaposi.) 

those from the cow being of less formidable character. Tilbury Fox 
reports an especially aggravated case originating in the disease as it 
existed upon a pony. It occurs much more frequently in children 
than in adults, presumably from the relatively tender condition of 
the epidermis in these subjects. It is particularly liable to occur in 
men whose skins are especially moistened, as in those who work in 
atmospheres saturated with steam. Several members of a single 
household will often display ringworm of the body at the same time, 
having transmitted it, the one to the other. Duhring and Fox are 
in accord respecting a belief in the need of an appropriate soil for 
the germination of the fungus, some individuals being thus predis- 
posed to its invasion. It is, however, encountered in both sexes and 
in all social conditions. 

Pathology. — The seat of the fungus in tinea circinata is between 
the strata of the epidermis, that part of it more .particularly which 



1 Lyon Medical, April 24, 1881, p. 590, and May 1, p. 7. 



724 DISEASES OF THE SKIN. 

lies immediately beneath the stratum corneurn, the superior layers of 
the rete. Here the trichophyton can be discovered with the micro- 
scope ; at an early stage of the disease, in the form of spores only; 
in the course of a few weeks exhibiting characteristic mycelium. 
The latter is much more scantily developed than in favus • much less 
branched and reticular ; and the threads more slender. Like the 
elements in favus, however, these are jointed and divided into com- 
pound cells by partition walls. The spores are also often strung 
together like the beads on a necklace. The former measure 0.0018 to 
0.0026 mm. ; and the latter, 0.0021 to 0.0035 mm. (Duhring.) 

After the fungus has found its way to the surface of the skin 
favorable to its development, it penetrates the layers of the epidermis 
in every direction from the central point of invasion, the circle thus 
produced being characteristic of many forms in both the higher and 
the lower vegetable life. The irritation excited by the presence of 
this foreign body produces all the subsequent symptoms of a mild 
grade of superficially seated inflammation ; erythema, exudation and 
fine vesiculation, papulation, and, in severe grades, the production of 
tubercles and pustules. The desquamative symptoms are exfolia- 
tive ; and represent, in a sense, the natural effort at relief; this effort, 
as remarked above, being often successful when the spores and sporo- 
phores are thrown off with the effete, horny plates of the epidermis. 
When the nails are affected, the same fungus can be discovered in 
detritus of the nail-tissue, which has been macerated in dilute liquor 
potassse. Often, as a result of the impairment of the structure of 
this organ, and owing largely to the stratification of its body, the 
lamella? will be found in part to have undergone a caseous degenera- 
tion. 

Diagnosis. — Ringworm of the body is to be distinguished clini- 
cally from eczema, psoriasis, seborrhoea, lupus erythematosus, herpes 
iris, and syphilis. All the varieties of eczema are noted for their 
greater degree of itching and infiltration, their much less defined 
border, coarser scales, decided absence of a circular contour, and of a 
history of contagion. Psoriasis does occur in circular and annular 
patches, often with a clear centre and insignificant, subjective sensa- 
tions. But its scales are lustrous and the tissue beneath them readily 
bleeds, showing deeper implication of the skin. The disease is often 
symmetrical in disposition ; occurs by preference upon certain regions 
of the body where ringworm is relatively infrequent ; and its history 
is that of a chronic disorder. Seborrhoea of the skin exhibits greasy 
or fatty crusts, which are never characterized by the peculiarly branny 
condition of the scales seen in ringworm of the body. The distinc- 
tion between these disorders on the scalp will be given later. Lupus 
erythematosus is often symmetrical, generally chronic, and characterized 
by the development of multiple, annular patches, eularging centrifu- 
gally from a clearing centre. Herpes iris can be distinguished, first, 
by its predilection for the extremities ; second, by the variegations in 
color which it displays and which are never seen in ringworm of the 
hands. Syphilis is multiform in its lesions, usually preceded by a 



TINEA TRICHOPHYTINA. 725 

history of infection ; and its distinctly circular patches, enlarging at 
the periphery, all exhibit either atrophic, ulcerative, or distinctly 
crusted symptoms, which suffice for their recognition. 

Pityriasis maculata et circinata is not characterized by vesicles ; is 
often symmetrical in development; occurs in oval rather than dis- 
tinctly circular patches ; and exhibits a characteristic tawny-yellowish 
shade of color not seen in ringworm. In eczema marginatum, the 
elevated border of the diseased surface, its situation (groius, armpits, 
pubes, etc.), its curved outlines, and the occurrence of fresh rings 
within the older, point to the nature of the trouble. 

But the microscopical discovery of the parasite is the chief, and 
indeed, essential, method of diagnosis in tinea circinata. By the aid 
of a good fourth- or fifth-inch objective, the spores and mycelium 
are readily recognized in the scales scraped from the surface and 
moistened with dilute liquor potassse. Dun ring calls attention to 
the care which should be had in distinguishing the fungous elements 
from cotton or wool fibres, fat globules derived from previously 
applied unguents for the cure of the disease, sebum, pus, and the 
nuclei of the epithelia. All confusion of this sort can be avoided by 
a careful study of the anatomical peculiarities of the trichophyton, 
recalling especially the parallelism seen in the double contours of the 
threads, their jointed appearance, their contained granules, and the 
necklace-like or beaded arrangement of many spores. 

Treatment. — The indication in the treatment of ringworm of the 
body is the removal of the superficial layers of the epidermis, by 
which means the spores and mycelium are thrown off from the surface ; 
and, if possible, the simultaneous destruction of the latter. Upon 
the delicate skins of infants and children, the simpler remedies are 
first to be employed. Scrubbing each patch with the spirit of green 
soap, or merely soap and water, will often suffice for its obliteration. 
The topical application of tincture of iodine is a common and usually 
effective remedy. The same may be said of dilute acetic, boric, and 
carbolic acids. Morris's solution of thymol, 1 half a drachm to two 
drachms (2.-8.) of chloroform, and six drachms (24.) of olive oil, is 
equally available. One may also use thymol in ointments, half a 
drachm (2.) to the ounce (32.) of simple unguent, with good effect. 
Of the mercurials, ammoniated mercury, a scruple (1.33) to the 
ounce (32.) of ointment ; corrosive sublimate, one to two grains 
(0.066-0.133) to the ounce (32.) of solution ; and the ointment of the 
nitrate, one drachm (4.) to the ounce (32.) of vaseliue, are preferable. 
Sulphurous acid from a freshly opened can, and saturated solutions 
of the hyposulphite of sodium are as effective as any of the parasiti- 
cides, and are often used with advantage as lotions, to be followed by 
an appropriate unguent, always providing against chemical decompo- 
sition of the ingredients of the latter. Sulphur- and tar-containing 
lotions and unguents are useful in more obstinate cases. 

Chrysarobin and pyrogallol, in ointment, from five to ten grains 

i Lancet, 1881, pp. 164 and 241 . 



726 DISEASES OF THE SKIN. 

(0.33-0.66) to the ounce (32.), are brilliantly effective in all these 
cases, subject, however, to the disadvantage incidental to the staining 
and irritative effects they produce. They should be used with cau- 
tion upon the skins of children, and always tentatively at the onset. 
In cases of ringworm on the face of male adults, close to the beard 
or scalp, one may employ these remedies with a view to insure the 
non -invasion of the pilary follicles by the fungus, whose prompt de- 
struction may become then a matter of urgency. Wilkinson's oint- 
ment, recommended by Kaposi, is also useful in the treatment of 
aggravated forms of ringworm of the body, but should be restricted 
to such cases. For other and more urgent reasons, caustic potash 
solutions should be reserved for exceedingly intractable cases. Some- 
times a combination of several of the simpler remedies named above 
may be serviceable, as in the following formulae : 



H. Lac. sulphur. 


3ijss; 


10 




Sapon. virid. spts. \ 
LavanduL tr. J 


aa 3vj; 


24 




Glycerin. 


3ss; 


2 


M. 






[Kaposi.] 


K . Iodin. pur. 


3ii; 


621 


01. picis [sp. gr 0.853] 


3j; 


341 


ix with care, gradually. 






R . Creasoti 


nix*; 


133 


01 cadini 


f 3 ir J; 


12 




Sulphuris prsecip. 


f^Hi; 


12 




Potass, bicarb. 


3j; 


4 




Adipis 


3j; 


32 


M. 


3 be used in obstinate ringworm 


of adults. 


[Van: 


rlarlingen.] 



Dr. R. W. Taylor applies the bichloride of mercury, four grains 
to the ounce, in tincture of myrrh. Dr. Perry, of California, uses 
the metal in one-half of the strength last named, dissolved in sul- 
phuric ether. Foulis, of Edinburgh, recommends iodine dissolved 
in the oil of turpentine or benzine, the fluids named penetrating with 
greater ease than others, to the deeper portions of the skin. 

Other articles advised by authors are the oleates of mercury and 
copper (?), croton oil, glacial acetic acid, cantharidal collodion, petro- 
leum, and pyroligneous acid (Thomas). 

The thorough application of the remedy selected for use, upon the 
integument quite freed from its scales by scrubbing with soap and 
water, is a matter of some importance. When the solution of sodic 
hyposulphite is employed, the previous application of dilute vinegar 
and water by sponging, renders the agent more effective, for evident 
chemical reasons. Overtreated skins, or those to which too strong 
a parasiticide has been applied, require subsequent relief of the 
induced irritation by the simpler bland dressings. The inert dusting 
powders, even when not thus indicated, are often useful when there 
is distinct vesiculation ; and in simple cases may be the sole remedies 
required, as then the disease is self-limited in duration. 






TINEA TEICHOPHYTINA. 727 

Liborius, having observed in China that the tincture of an un- 
known fibrous root was used successfully as a remedy for ringworm, 
obtained some of the plant, which was found to be the Rhinacanthus 
communis, whose leaves, braised and mixed with lime-juice, are used 
in India as an application for the same complaint. Liborius has 
since obtained from the root a quinine-like body, supposed to be the 
active constituent. It resembles chrysarobin in being antiseptic and 
antiparasitic. He proposes to call it rhinacanthiu, and represents it 
by the formula C 14 H 18 4 . 

The internal treatment of patients affected with ringworm, by 
means of tonics aud roborant measures, may be demanded by the 
systemic condition, but has no recognized influence over the disease 
itself. 

When the nail is involved it should be thoroughly scraped, and 
then kept moist by wearing over it the rubber cots sold in the shops 
for the use of sportsmen, fishermen, and others. In this way a par- 
tial maceration of the nail substance is secured, and the action of any 
one of the parasiticides named above, greatly aided. 

Prognosis. — This disease is often self-limited, and is generally, 
under the simplest treatment, satisfactorily relieved. Eczema mar- 
ginatum, especially in the crural region, may be obstinate ; and this 
because it is an eczema as well as a parasitic disease, and therefore 
subject to the relapses and chronic phases of the first-named disorder. 
Other intractable forms of the malady do, however, occasionally occur 
in adults, usually in tropical climates and tropical temperatures. 



[B.] Tinea Tonsurans. 

(Ringworm of the Scalp; Herpes Tonsurans; Tinea Tondens. 
Gee., Scheerende Flechte ; Fe., Teigne tondante.) 

Statistical frequency in America, 0.545. 

Tinea Tonsurans is a cutaneous disease of the scalp, characterized by the occur- 
rence of one or several, circumscribed, non-elevated or tumid patches, over 
which the hairs are usually fractured at a point near the integument, pro- 
ducing thus the effect of partial baldness, while the scalp itself is the seat of 
vesiculation, scaling, or crusting, the disease being produced by the presence 
of the trichophyton. 

Ringworm of the scalp is a disease chiefly of children ; and among 
the latter those resident in their own homes, but chiefly those congre- 
gated in public institutions for their care, education, and training, 
The gregarious habits of children and the frequency and intimate 
character of their contacts in their amusements and studies, greatly 
increase the chances of contagion when one of their number is af- 
fected with ringworm of the scalp. As a consequence, the early 
recognition and relief of the disease furnish problems among the 
most important presented to the general practitioner as w r ell as to the 



728 DISEASES OF THE SKIN. 

dermatologist. Important considerations relating to the segregation, 
and, with that secured, the education of children, are wrapped up 
with the question of treatment. Nor should the physician examin- 
ing and giving advice about the scalp of a number of children, forget 
that his hands may transmit the disease to those as yet unaffected. 

Symptoms. — The differences to be particularly noted between ring- 
worm of the body and ringworm of the scalp depend largely upon 
the fact that in the latter the fungus makes its way to the hair- 
follicles, and there finds the nutriment for its multiplication and 
development. 

The disease begins at one or several points by involvement of the 
hair-follicle, which becomes slightly tumid and reddened. The 
symptoms usually first observed are circumscribed, small coin sized, 
roundish patches upon the scalp, wholly or partly covered by minute, 
whitish, slate-colored, grayish, or dirty yellowish scales. Sometimes 
the formation of the latter can be observed as they develop upon an 
hypersemic and reddened condition. Still more rarely, pin-point 
sized, transitory vesicles or pustules precede. The hairs upon such 
a patch seem irregularly clipped short near the surface or, as it is 
frequently styled, " nibbled " off, thus producing the effect of partial 
baldness in the involved area. Among them may be often found 
lustreless, dry, long, and fragile hairs, which break upon slight trac- 
tion or flexion. The patches may increase in number and spread 
individually in area till, in the course of weeks or months, the entire 
scalp is invaded. In the older patches, young and downy hairs may 
be seen here and there, pushing up among the stumps left by those 
that have fallen. One or more of various phases of the disease may 
be presented in its subsequent evolution. Thus a single patch may 
extend to the size of a large coin or the palm, and the disease be 
throughout limited to that area. Again, as just related, almost the 
entire scalp may be covered by relatively small or enlarging patches, 
or, even without the occurrence of any distinct patch, isolated hairs 
or tufts of hairs here and there over the entire scalp may exhibit 
evidence of impairment. The hairs, instead of " staring " from the 
patch, may be twisted, imbricated, or matted together and covered 
with grayish scales. The disease may be acute or chronic in its 
course. Instead of assuming the dry and squamous type described, 
acute and exudative symptoms may develop, in which event the rare 
vesicular and pustular lesions are succeeded by the exudation of a 
gummy secretion aud the formation of crusts. Lastly, the variety 
known as kerion may be produced, which is described below. 

Pruritus, in various grades of severity, though usually mild, is 
induced by the disease ; and often the patches are altered in appear- 
ance by the traumatisms produced by the finger-nails and the comb. 
When the scalp is very generally invaded by the squamous form of 
the disorder, its appearance is very similar to that noted in diffuse 
seborrhcea, chronic eczema, and psoriasis of the scalp, except that the 
hairs are less pasted to the surface ; are more lustreless, friable, aud 
contorted in shape ; aud much more often represented by stubble or 



TINEA TRICHOPHYTINA. 729 

stumps. The disease may occur eoincidently with ringworm of the 
body, and indeed at times a ring may be detected, half of which 
on the neck presents the typical aspect of tinea circinata, and the 
other half involving the scalp exhibits the features here described. 
Stowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and 
others have recorded cases in which the disease coexisted with alo- 
pecia areata. 

Geber asserts that after exfoliation of patches of ringworm, the 
scalp may, in cases, become absolutely bald, smooth, and glossy, but 
that hair-stumps aud scales in the environment indicate the nature 
of the disease, which is thus often mistaken for area Celsi, or alo- 
pecia areata. 

This is the " Bald Tinea Tonsurans " of Liveing, cases in which the 
smoothness and baldness of the scalp have produced the error that 
alopecia areata was present, an error readily corrected by the recogni- 
tion of scaling patches with hairs, exhibiting under the microscope 
evidences of the existence of the fungus. It is to be remembered 
that in all such persistent scaling patches left after treated or un- 
treated ringworm of the scalp, the possibility of contagion is not 
averted. 

The " Disseminated Ringworm " of Alder Smith is represented by 
individual pilary filaments, rather than by patches, where the disease 
is in insidious progress, a broken stump, or a group, or a relatively 
small number, of lustreless, dry, and friable hairs presenting the 
evidences of the disease. 

Lastly, it is to be noted that here also at times the efforts of nature 
are successful in obtaining spontaneous relief. With the defluvium 
capillitii and exfoliating epidermal plates, the fungus maybe finally 
removed ; the resulting alopecia be followed by a growth of healthy 
pilary filaments ; and, even though years be required for this long 
process, in the end no trace of the disease be discernible. 

Etiology. — Ringworm of the scalp is produced by the fungus 
recognized in the etiology of tinea circinata, the trichophyton. It is 
frequently observed in children of both sexes, especially in those 
gathered together in schools and public charities, where it may spread 
very generally from one to another, and require months and years 
for its extermination. It is a highly contagious disease,, but yet re- 
quires unquestionably a suitable soil for its development. I have 
been frequently impressed with a fact in this connection to which 
Dr. White 3 calls attention. When there is ringworm on the face of 
an adult, even of rebellious form, in the course of which the beard 
may be extensively affected, the scalp is usually spared. Ringworm 
in the scalp of the adult and aged is, indeed, among the rarest of 
cutaneous accidents. Among the methods of transmission in chil- 
dren are, the use upon the heads of the unaffected, of brushes, combs, 
wearing apparel, sponges, towels, etc., which have been employed 
upon persons exhibiting ringworm of the body or head. It must 

i Lancet, 1881, p. 326. 2 id., 1880, p. 303. 3 Loc. cit. 



730 



DISEASES OF THE SKIN, 



be remembered that tinea circinata may transmit tinea tonsurans; 
and it is by tracing the course of the two forms of the disease, that 
the sources of contagion can be ascertained in any series of cases. 
The disease is one rather prevailing in the cities than in the country; 
and in this respect also differs from favus. 

Pathology. — The disease is produced in consequence of the invasion 
of the scalp and follicles, bulbs, aud shafts of the hair, by the tricho- 
phyton, the fungus already described as the cause of tinea circinata. 
This vegetable mould is much more abundantly developed about the 
hairs than the achorion Schonleinii, and its presence is, hence, much 
more readily demonstrated in these structures. 

Robinson 1 excised a portion of a scalp affected with tinea ton- 
surans, and found the stratum corneum, especially in its upper 



Fig. 93. 







■i%P%&%& 



Hair invaded by the trichophyton. 

layers, largely invaded by spores, as also the rete, the external root- 
sheath of the hairs in its upper portion, the corium, and subcuta- 
neous tissues. Mycelium was abundant in the mucous layer. He 
concludes that the anatomical seat of the disease diners in different 
cases. 

Under the microscope the hairs themselves, in advanced cases, are 
seen to be greatly altered. The bulbs are distorted, misshapen, or 
withered, and often stuffed with spores which greatly predominate 
over the mycelium. At times the base of the bulb will show a brush- 
like expansion, and in this respect resemble the free ends of the 
stumps of the hairs above, which have a jagged, bristle-like appear- 
ance, from the division of the shaft into many filaments between 
which spores in abundance are visible. The shaft is often longitu- 
dinally split, where the parasitic growth has mechanically forced 
apart its elements, and its cuticle may be peeled off, or curled above 
and below away from the axis, with spores protruding at such points. 



1 New York Medical Journal, 1881, vol. xxxih". p. 289. 



TINEA TRICHOPHYTINA. 731 

Conidia can be discovered much further upward along the hair and 
distant from the scalp than in favus ; often, indeed, upon its free 
surface. Occasionally a few mycelial threads may be recognized, 
either longitudinally or transversely arranged as regards the axis. 
It is probable, however, that the relative preponderance of spores 
and mycelium in these filaments, is determined by the stadium of the 
disease in any given case. In the earlier stages of the affection the 
elongated threads may be discovered in larger quantity ; and as they 
interfere less with the integrity of the fibrous tissue, the hair may 
usually at these times be extracted from its follicle without fracture. 
Later, the threads disappear and the conidia are infiltrated throughout 
every portion of the shaft which then breaks, often upon the slightest 
traction. One unaccustomed to microscopical examinations with a 
view to the detection of the parasite, should be careful not to mistake 
for these threads the delicate lines traversing the surface of the shaft 
exposed to the objective, and which represent the edges of the cuticle 
of the hair. The fungus, though ordinarily refractory to the action 
of coloring matters, will be stained by eosine and methyl- violet. 
The scales found upon the affected scalp also exhibit traces of the 
trichophyton under the microscope, though to a less extent than the 
invaded hairs. In exceptional cases, however, the epidermis of the 
scalp seems to suffer as much as that of the non-hairy portions of 
the body. 

Furthmann, Xeebe, and Sabouraud (Annales de Derm, et de Syph , 
Nov. 1892), describe several varieties of trichophyton, with small, 
with large, and with mixed spores of differing sizes. These are not in 
reality different species of one fungus, but variations of development. 

As to the mode of invasion, it is still disputed whether the spores 
find access to the fundus of the follicle between the shaft and the 
follicular wall, or by penetrating the cuticle of the hair shaft at the 
level of the epidermis. It is possible that invasion may occur in 
both ways. 

Diagnosis. — The recognition of a typical patch of ringworm of the 
head is simple. The branny scales, clumps of hairs, and distinct 
contour of the invaded area, are always in the highest degree suspi- 
cious symptoms. It has been stated, however, that the general 
development of tinea tonsurans over the scalp produces a condition 
very like that seen in other diseases. In such cases the microscope 
must be employed for a decision as to the nature of the process. I 
have seen the whole vertex unnecessarily epilated in seborrhcea sicca, 
when no parasite could be found. But in seborrhcea there is usually 
a symmetry of involvement which even aggravated cases of ring- 
worm of the head fail to assume ; and even though pasted down, 
atrophied, changed in color, and loosened in their follicles, the hairs 
are rarely broken off near the scalp in seborrhcea. In seborrhcea, 
psoriasis, and squamous eczema of the scalp, there is, moreover, no 
history of contagion ; the scales are in each disease different in color 
and character ; and the hairs in the two last-named affections are 
firmly fixed in their follicles, and only in severe cases present nutri- 



732 DISEASES OF THE SKIN. 

tional changes. The diseases, moreover, are usually chronic in their 
course. In any doubtful case, apart from microscopical evidence, 
thorough removal of all scales from the scalp by shampooing with 
green soap and hot water, will reveal the nature of the disease 
present. 

Alopecia areata, as has been noted above, may coexist with ring- 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, aud the hair falls from them 
en masse, without lesions, stumps, or other traces of previous involve- 
ment of the regions affected. I have, however, often seen blackish 
points or dots distributed over the areas which characterize this form 
of alopecia, and which certainly constitute suspicious symptoms in any 
case. In such event, one may at times be able to pick out with a fine 
needle this blackish point from the patent follicular orifice, and find 
it to be a particle of dust accidentally lodged in the depression. It 
is not, as in comedo, free pigment which has found its way to the 
surface ; nor, as in ringworm, the stump of a hair on a level with 
the superficies of the scalp. In favus, the cup-shaped crust will 
sooner or later betray the character of the disease to the naked eye. 

Confirmatory evidence as to the nature of the disease will often be 
furnished by a careful search for the source from which it was de- 
rived ; and for obvious reasons this should be always attempted. 

Ringworm of the body occurring upon the individual patient 
affected with tinea tonsurans, or other members of the same house- 
hold, and suspicious " mangy " patches upon horses, dogs, cats, 
rabbits, white mice, or other animals with which the child may have 
been in contact, should always receive attention. 

Treatment. — The indication for the relief of the disease is the 
destruction of the parasite ; and there can be no question but that 
this may be accomplished in some cases without having recourse to 
epilation. The parasiticides named in connection with ringworm of 
the body, if thoroughly applied in simple cases, after clipping or 
shaving the hair and an efficient scrubbing of the patch with spirit 
of green soap and water, will occasionally be followed by permanent 
relief. Prominent among these parasiticides may be named : pyro- 
ligneous acid, sulphurous, acetic, salicylic, and boric acids, saturated 
solutions of the sodic hyposulphite, acetum cantharidis, tincture of 
iodine, Crocker's thymul in ointment, one part to four ; Morris's 
solution of thymol in chloroform and olive oil (see Tinea circinata), 
ointments of boric acid and sulphur, of each a drachm (4.) to the 
ounce (32.) of vaseline, and chrysarobiu, the action of the latter 
being carefully limited to the patch of disease by the aid of a skull- 
cap. 

Epilation is, however, a valuable, and occasionally essential, method 
of treating the disease ; and may be practised, as already recom- 
mended, in considering the treatment of favus. The scalp in each 
case should be first oiled, and cleansed by the soap shampoo, and, 
after the epilation is performed, an appropriate parasiticide should be 
employed. The calotte, made by spreading pitch plaster upon leather 



TINEA TEICHOPHYTINA. 733 

or niuslin, is a brutal substitute for epilation in order to remove the 
hairs, but the sticks recommended by Bulkley may be employed, the 
formula for the preparation of which has been already given. In 
each case, the epilation should remove a zone of sound hairs encir- 
cling the diseased patch, that the encroachments of the fungus may 
be in every possible way limited. It should not be forgotton, how- 
ever, in the treatment of tinea tonsurans by both epilation and para- 
siticides, that in chronic cases these methods, in the hands of the most 
expert, have failed for consecutive months to relieve radically the 
disease ; that even the most inveterate cases, in the course of time and 
as adult years are reached, are spontaneously relieved without perma- 
nent alopecia ; aud that no remedy or procedure is ever justifiable 
which is capable either of producing follicular atrophy, or an effect 
worse than that wrought by the disease itself. 

Coster's paste is popular among English practitioners, including 
Stowers, Fox, Liveing, and others. It contains two drachms (8.) of 
iodine in crystals, slowly dissolved in the oil of tar ; and is painted 
over the part at intervals of a few days. It is most useful in circum- 
scribed patches of the disease. Among other remedies employed, 
some of which have been described in connection with ringworm of 
the body, may be named, the corrosive chloride, ammonio-chloride, 
red oxide, oleate, and ointment of the nitrate, of mercury ; epispastics, 
pure carbolic acid, and carbolated glycerin ; and sulphur, chloroform, 
ether, and tar in ointment. 

In order to be effectual, the treatment pursued must be persistent, 
thorough, and always accompanied by frequent washings and soap- 
ings of the affected part. 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion) by the aid of electrolysis and croton-oil liniment, has 
been praised by Alder Smith and Wyndham Cottle, of London, and 
lately, in a modified form, by Magee Finny, of Dublin. By the 
process of the latter, one hundred parts of the oil are mixed with fifty 
each of cacao-butter and white wax. Sticks are made of the com- 
pound which can be thoroughly rubbed into the part affected. By 
both methods, it is claimed that no pain is produced, nor is perma- 
nent alopecia the result. A solution of salicylic acid is applied after 
each treatment, and a subsequent poultice may be also needed. In 
these cases the parasite is presumably destroyed by the suppuration 
excited. 

Dr. James Foulis, of Edinburgh, claims to relieve the worst cases 
in a week by the following method : The patient (usually a child) is 
seated before a basin of warm water with a towel fastened around the 
brow so as perfectly to protect the eyes from the trickling into them 
of the fluids used. About the patches, the hair is cut short ; if the 
patches are numerous, the entire scalp is closely cropped. The oil 
of turpentine is first thoroughly rubbed in with the finger, causing 
the dirt and greasy scales to disappear while the short broken hairs 
are seen to stand up like bristles. The scalp is then well sham- 
pooed with hot water and ten per cent, carbolic soap. The head is 



734 DISEASES OF THE SKIN. 

then well dried and two or three coats of iodine in tincture are 
painted over each affected patch and permitted to dry. Carbolic 
oil, one part to twenty, is then rubbed into all the hairs of the head 
with a view to reaching any spores among them. The treatment is 
employed once or twice daily, according to the severity of the case, for 
a week. Chloroform, ether, or benzol, may be substituted for the 
turpentine. 

As in the case of ringworm of the body, tinea tonsurans is not 
remediable by internal treatment. Such internal medication, how- 
ever, may be indicated by the systemic condition of the little patients, 
and should be in each instance such as that condition suggests. 

Prognosis. — The ultimate prognosis in every judiciously treated 
case of tinea tonsurans is favorable, since all patients ultimately re- 
cover from the disease per se. Under the best treatment many cases 
prove extraordinarily tedious, month after month passing without 
marked improvement. The disease, however, in a large proportion 
of cases among children surrounded by proper hygienic conditions, 
especially as regards cleanliness, is readily relieved. 

Tinea Kerion. — The occurrence of active inflammation in a 
usually circumscribed portion of the scalp affected with ringworm, 
is at times followed by certain peculiar features, the assemblage of 
which has been designated by this term. This complication of the 
disease was recognized early in the history of medicine, by Celsus, 
whose name has since been associated with its lesions (Kerion Celsi, 
from iujp'iov, a honey-comb). Tilbury Fox, in 1866, was first to recog- 
nize its identity with tinea tonsurans ; and it has since been the sub- 
ject of a number of interesting papers by Tanturri, Maiocchi, Schil- 
ling, Barduzzi, Auspitz, and Wilson. In this country, Dr. I. E. 
Atkinson, 1 of Baltimore, has made it the subject of a valuable 
memoir. 

The symptoms are, the occurrence of acute inflammation, usually 
circumscribed, though occasionally diffuse, in a portion of the scalp 
where a tumor forms which may project to a considerable distance 
above the general level. In time the appearance presented is quite 
suggestive of anthrax benigna, as from tumid orifices of numerous 
distended follicles, a viscid, semi-transparent, and puriform fluid 
exudes. The latter is highly characteristic. The hairs loosen and 
fall. When the view of the lesion is not obscured by the pilary 
growth it appears as a flattened hen's to turkey's egg sized, boggy, 
semi- globular tumor, its surface congested, reddened, glazed, and 
often exhibiting other evidences of inflammation, with split-pea 
sized, pustule-like lesions distributed over its surface, or, when these 
have ruptured, the gaping apertures described above, from which 
the gummy secretion is poured in varying quantities. Modifications 
of this condition occur, such as the production of a true subcuta- 
neous abscess with fistulous sinuses. The sensations awakened are 

1 Arch, of Derni. , vol. vii., No. 1, Jan., 1881. 



TINEA TRICHOPHYTON A. 735 

usually painful; the course of the disease is chronic. It may begin 
with the usual symptoms of ringworm of the head, though often 
there is no history of the latter. The complication is a rare one. 
About one dozen cases in all have come under the author's observa- 
tion ; two of these were of children in one family, brought from a 
neighboring State. 

The parasite may and may not be found in patches of kerion, 
according to the acuity of the present or precedent inflammatory pro- 
cess. If the latter be of high grade, and suppuration result, the 
fungus is destroyed, a result whose attainment has been attempted in 
the production of an " artificial kerion " by means of croton oil for 
the relief of tinea tonsurans. In the earlier stages, well described 
by Atkinson and represented by merely deep-seated follicular in- 
flammation, with pustular development about the hair-shafts, the 
latter may be seen microscopically to be invaded with spores. 

The treatment is either by the milder parasiticides or by the 
methods proper for the relief of ordinary phlegmonous inflammation 
of the scalp, according to the stage of the kerion. The pus cocci 
present in some of these cases require boric acid lotions and bichloride 
washes. 



[0.] Tinea Sycosis ; Hyphogenous Sycosis. 

(Tinea Barbae : Sycosis Parasitica; Mentagra Parasitica; Ringworm 

of the Beard ; " Barber's Itch." Ger., Parasitare 

Bartfinne; Fr., Trichophytie sycosique.) 

Statistical frequency in America, 0.295. 

Tinea Sycosis is a contagious disease of the region covered by the beard of the 
adult male, in which the integument, hairs, hair-follicles, and subcutaneous 
tissues may be involved, characterized by the occurrence of macular, papular, 
vesicular, pustular, or tubercular lesions, owing to the presence of the tri- 
chophyton. 

Symptoms. — The disease is best studied at its onset, in the beard 
of a blond subject with relatively fine downy hairs, where are pre- 
sented the typical features of tinea circinata, ringworm of the body. 
One or several, reddish, pea- to small coin-sized rings become visible, 
with pin-point sized vesicles, branny scales, and often, indeed, no 
other lesion save an hypersemic, scarcely elevated margin at the 
periphery. The hairs over the patch may be fragile, and clusters 
here and there betray evidences of change. With proper treatment 
the disorder may not progress beyond this point. 

In other cases the very slight degree of itching awakened by the 
process just described may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or vice versa. When fully developed, a phlegmonous 
disorder is produced which bears some analogy to the kerion just de- 
scribed, and which may so actively progress that it is first seen in 



736 DISEASES OF THE SKIN. 

typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifices of the pilary 
follicles; and is studded irregularly with firm, pea- to nut-sized 
papules and tubercles. The latter are usually aggregated in masses 
or lumps which involve the skin and subcutaneous tissues ; and are 
firm, often tender and painful, rarely boggy and furuncular. When 
pierced they give exit to a characteristic, muciform, gluey, yellowish, 
and sticky fluid, puriform yet differing from pure pus, which rapidly 
dries into crusts. These composite lesions are usually circumscribed 
in a given area of involvement, very rarely covering the region of 
the beard in symmetrical disposition, more often limited to one cheek, 
or the cheek and chin. Duhring has an admirable portrait of this 
disease in his Atlas, one of the most faithful representations of a 
cutaneous affection which it is possible to produce. 

The hairs in the invaded region are involved as in ringworm of 
the scalp. These filaments break near the surface of the integument, 
leaving ragged stumps ; or spontaneously fall, after being loosened 
in their follicles. 

The ease with which they may be epilated is really one of the most 
characteristic features of the disease ; they are slipped out of their 
follicles as readily as if they had been oiled ; or, as Anderson re- 
marks, " as easily as a pin can be pulled out of a pin-cushion." 
They are then often whitish because enveloped in the fungus pro- 
ducing the disease. In either event, the resulting, gradual thinning, 
or removal of the hairs, renders the disease of the surface more con- 
spicuous and deforming. At the edges of a patch thus exposed, 
deformed, lustreless, contorted, flattened, twisted, or split hairs may 
be found. Occasionally the features of the patch are changed in 
consequence of the unusual degree of suppuration excited. In such 
case the pustules burst, and their contents concrete into dry crusts 
about the stumps of shafts of surviving hairs, from which circum- 
stance the disease has received its name (sycosis, vvkov } a fig). Rarely, 
a conglomerate crust covers the entire region with an excoriated, 
inflamed, and secreting surface beneath. 

During the last few years the author has had the opportunity of 
treating a number of formidable cases of tinea sycosis in the persons 
of farmers resident in the extreme western part of the United States, 
where the disease was long untreated and unrecognized. A few of 
the severe cases were produced after shearing sheep having diseased 
pelts. In these cases the cheeks, lips, and chin were the seat of nut- to 
fist-sized and larger cutaneous and subcutaneous, soft, boggy, and pus- 
filled tumors, accompanied by excessive soreness of the entire throat 
and neck, the hair falling from the follicles in large masses, and as if 
lubricated to facilitate their escape. 

Etiology. — The disease is always produced by the trichophyton, 
the fungus described as the cause of ringworm of the body and scalp. 
It was first discovered by Gruby, in 1844. Dr. White, 1 of Boston, 

1 Loc. cit. 



TINEA TR1CH0PHYTINA. 



737 



has called special attention to the frequency of its origin in the 
barber's shop, a fact which common experience verifies. It is usually 
the irregular visitor to these establishments who is first to supply the 
germs of the disease. No individual proprietorship in mug, soap, 
brushes, and razor can secure against danger of infection the person 
whose razor is drawn over a common strop, whose cheek is handled 
by unwashed fingers which have been recently passed over an infected 
face, or whose beard is combed, brushed, or rubbed by the imple- 
ments and towels in common use at these establishments. The 
remedy is twofold : first, the full beard should be worn without 
shaving, as it is rare to find bearded patients of this class affected 



Fig. 94. 




Filaments and spores of the trichophyton from the beard of 
with tinea sycosis. 



patient affected 



with tinea sycosis ; second, where the whole or any part of it is to be 
removed, every adult male should learn how to shave himself. The 
physician should, in this connection, for medico-legal reasons be 
upon his guard against hastily deciding both as to the nature of the 
disease of his patient and the source from which it was derived. Of 
the first, he can become certain by his microscopical investigations. 
Of the second, he can only become certain by obtaining possession of 
facts far beyond the reach of the average practitioner. A medical 
gentleman in a neighboring State once sent the author for exam- 
ination some hairs from the beard of a male patient affected with 
tinea sycosis. Before receiving a report confirming the diagnosis, 
this physician was sued by the barber in whose establishment the 
disease had been probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from 
statistics. The affection is certainly relatively rare, and yet more 

47 



738 DISEASES OF THE SKIN. 

common than is frequently supposed to be the case. In the author's 
practice it is of irregular occurrence, months passing without a single 
case coming uuder observation, after which several may be noted in 
rapid succession. The statistical returns of the American Dermato- 
logical Association included eighty cases in the year 1885 ; ninety- 
seven in the year 1886 ; and but twenty-two in the year 1887. 

The disease, being contagious, is one affecting men in all stations 
of life, and these usually at a period rather under than over the 
fortieth year. The author has certainly treated for this disease more 
men with light hair and eyes, and light brown, reddish, or sandy 
beard, than those having darker shades of hair and eyes, a fact to 
which Mr. Morris has called attention in connection with tinea 
tonsurans. 1 

Pathology. — The disease is essentially a follicular and perifollicular 
inflammation, induced by the irritative effects of the fungus, pre- 
cisely as in the case of tinea tonsurans. The difference between 
the clinical aspects of the two diseases may be in part explained 
by the habitual covering of the scalp with caps and hats, while 
the face is left exposed ; and by the occurrence, of tinea sycosis 
in adult years, while tinea tonsurans is emphatically a disease of 
childhood. As a result of the induced inflammation, the vesicles, 
pustules, papules, and tubercles are formed, while the perifollicular 
inflammation may invade all portions of the skin and subcutaneous 
tissues, gluing together the plastic nodules formed about the individual 
hair-sacs, into the lumpy masses which, are so characteristic of the 
disease. The invasion of the hair-follicles and hairs by the fungus, 
is accomplished as in the case of ringworm of the scalp. Under the 
microscope, spores and mycelium are visible, the former preponderating 
at the stage where the disease first comes under observation, but 
probably preceded in most cases by abundance of thread-like forms. 
The identity of the disease with ringworm of the body and scalp, 
does not, however, rest merely upon microscopical observation, but is 
demonstrable by established clinical facts. Not only may ringworm 
be seen to spread from the face to the beard, but tinea tonsurans and 
tinea circinata may transmit tinea sycosis, and the reverse. I lately 
treated a physician for ringworm of the bearded chin and cheek 
derived from the face of a little patient under his care. He subse- 
quently gave tinea circinata to his wife, who suffered on the face and 
shoulder, and she, in turn, communicated tinea tonsurans to her 
daughter. 

Diagnosis. — The distinction between coccogenous and hyphoge- 
nous sycosis is of chief importance in this connection ; and, necessarily, 
the microscope must be employed to settle the question definitely. 
The diseases, however, differ in their clinical features. The coccoge- 
nous form always fails to exhibit the nodules, tubercles, and com- 
posite cutaneous and subcutaneous agglutinations of the disease 
produced by the fungus. The process in the former is more 
superficial, and, in the author's experience, exhibits to the eye a 

i Lancet, 1881, pp. 164 and 241. 



TINEA TRICHOPHYTINA. 739 

more vivid redness as a result of the cutaneous hyperemia. Owing 
to the same cause, the frequent pus-containing lesions are developed 
and elevated above the general level of the integument ; they are 
less commonly sub-epidermic crypts filled with characteristic mucoid 
puriform contents. The region of the bearded upper lip, so often 
involved in cases of chronic nasal catarrh with coryza, is apt to be 
spared by the trichophyton. When the latter is present, the hairs 
are characteristically loosened, distorted, and otherwise changed. 
This is not seen in the coccogenous disease. Exception, however, in 
this particular is to be noted in some long-standing cases of the 
latter. When the affection has persisted for many years (and one 
may often see such patients), the thinned and starved condition of 
the pilary growth is a striking symptom, the scanty lustreless hairs 
often scarcely sufficing to conceal the deforming redness and pustula- 
tion of the surface from which they spring. In another point, the 
author's personal experience seems to differ from that of some other 
observers. The diffuse symmetrical affection of the hairy face, 
extending over both cheeks and chin, lias been by him more fre- 
quently recognized as connected with the presence of pus cocci. 
Lastly, the hyphogenous is, as a rule, less painful and tender than 
the other form of sycosis ; and is, without question, furthermore 
of much rarer occurrence. 

With respect to syphilis, it is to be noted that the papular or 
pustular syphiloderm developed in the beard is, almost without 
exception, to be discovered in other parts of the body, especially 
the scalp. Ringworm of the scalp and beard, existing at the same 
time in one individual, is very rare. In syphilis, there is usually an 
offensive odor to the abundant crusts ; shallow ulcers are also apt 
to form beneath the pustules ; and there is often a history of infection 
or a hint of the nature of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other por- 
tions of the face, as in the case where it . sweeps down from the ear 
above. The presence of a stalactitic crust, depending from the lobe 
of the ear of an affected side, would at once furnish a clew to the. 
nature of the disease in the beard. In eczema, the interfollicular 
region is invaded ; not deeply, as in tinea, but superficially, as in 
coccogenous sycosis. The itching is severe ; the hairs not involved ; 
the infiltration diffuse ; the outline indeterminate ; and a halo of red- 
ness spreads from the affected part to the non-hairy surface in the 
vicinity. 

Treatment. — The treatment of tinea sycosis is generally conducted 
as in tinea tonsurans. It is customary to begin by anointing the 
affected surface with an oily or fatty substance, and to follow this 
with a shampoo of soap and warm water for the removal of crusts, 
after which shaving and epilation are practised on alternate days ; 
and parasiticides employed locally. For the softening of the crusts, 
the spray of the atomizer may be used. 

Epilation of the male beard is often essential for the removal of 
the disease, but the results of the treatment suggested below may be 



740 DISEASES OF THE SKIN. 

in the end as satisfactory. It is true, that a month or more may be 
required for the removal of the disease, but that is often the period 
of time during which treatment by epilation must be pursued. 

The patient for two successive days keeps the affected part macer- 
ated with almond or olive oil. On the evening of the third day, 
the shampoo with soap is employed, and the skin washed free from 
all crusts and scales. The part is then cleanly shaved. The first 
is more painful than any subsequent similar operation. After the 
shaving, the affected surface is bathed for ten minutes in borated 
water as hot as can be tolerated, by which means the inflammatory 
condition of the perifollicular tissues is, in a brief time, considerably 
reduced. While the bathing is in progress, all sub-epidermic pus- 
tules or points where a mucoid fluid is coming to the surface are 
opened with a fine needle. A solution of the hyposulphite of sodium 
is then sponged freely over the surface for several minutes. This 
may contain a drachm (4.) to the ounce (32.) or even more. After 
a thorough and final washing w T ith the hot water, the tender skin is 
carefully dried and gently smeared with a sulphur ointment, contain- 
ing one or two drachms (4.-8.) to the ounce (32.) of vaseline, often 
with the addition of from one-quarter to one-half (0.016-0.033) of a 
grain of the red sulphuret of mercury. The patient then retires to 
bed. In the morning, the unguent is washed off with soap and 
water, the sodium solution reapplied, and a borated or salicylated 
powder thoroughly dusted, and kept over the part during the day. 
In the evening the shaving may be repeated or not, according to the 
vigor with which the beard is reproduced, but on the second day this 
is imperative. As soon as the pustulation ceases and the tubercles 
have manifestly diminished in size, the ointment at night is super- 
seded by the use, at that time also, of the dusting powder. Whether 
the shaving is practised nightly or on alternate nights, the ablution 
with very hot water and with the solution of the hyposulphite of 
sodium, is continued nightly until the inflammation excited by the 
fungus is practically limited to the follicles which are invaded. The 
dusting powder is to be thoroughly and constantly employed after 
the ointment is discontinued. With care and patience these meas- 
ures may save many patients from the annoyance of epilation. The 
treatment should be continued for several weeks after the apparent 
relief of the disease. 

The treatment may be varied to suit the needs of individual cases, 
Kaposi highly recommends, for example, one per cent, solutions of 
corrosive sublimate locally ; and the other parasiticides considered 
heretofore in connection with the treatment of ringworm may serve 
here also a good purpose. The author has, in cases, used an ointment 
of thymol with manifest advantage ; in others, a substitute may be 
found in Mr. Morris's solution of the same in chloroform and oil. 
The formula for this has been already given. In other cases, the 
stimulating spirit of green soap with sulphur ; finely powdered sul- 
phur, boric, acetic, and carbolic acids, or other topical applications 
of recognized value, may be employed. 



TINEA TRICHOPHYTINA. 741 

When resort is had to epilation, and this is essential in all severe 
cases, the hairs should be thoroughly removed from their follicles 
over every lumpy nodule, and even over every suspicious patch cov- 
ered with scales. A zone should be cleared about each such papule. 
The results are prompt, and in the highest degree satisfactory. 

Prognosis. — This disease is always remedied sooner or later, though 
at times tedious in its progress and characterized by relapse. 

Precautions to be observed in the General Management 
of Tinea Favosa and Tinea Trichophytina. — The physician 
consulted in the case of a patient aifected with either of the diseases 
thus far considered as resulting from the presence of a vegetable par- 
asite should bear in mind that they are the most contagious of their 
class. He may not only himself suffer from the disease which he is 
attempting to relieve in another, but also convey it himself to others, 
or be consulted by others of his patient's family, actually infected 
during the course of the treatment pursued. 

Generally it may be said that the hands of the physician should 
be carefully washed after each manipulation of the part, and prefer- 
ably by aid of a weak disinfecting solution. In the case of children, 
the lining of all caps, hoods, and other coverings of the head should 
be removed and destroyed by burning ; and fresh linings made of 
tissue paper renewed daily ; while paper caps of the same or similar 
material should be worn when indoors. Brushes, combs, towels, and 
articles of clothing should never be used in common by two or more 
individuals. When practicable, infected individuals should occupy 
separate beds ; and the bed-covering, clothing, toilet apparatus, and 
dressing or other materials which have been in contact with a diseased 
surface, should be immersed in boiling water before they are again 
employed for any use in common. Thin recommends covering every 
diseased patch, after the treatment appropriate to itself, with an 
adhesive and impermeable dressing, for the sake, not of the patient, 
but of those with whom the latter may be brought into contact ; and 
the suggestion is both wise and practicable. A gentleman infected 
with ringworm of the beard in a barber's shop which he has visited 
but once, will often, when directed by his physician to shave, resort 
to some other establishment, where he is well known, and where he 
has more confidence in the cleanliness of the operators. In this way 
he often thoughtlessly spreads the disease of which he is the victim. 
In his city, the author is in the habit of sending patients who can- 
not shave themselves, to a particular barber, who, being instructed 
in the manner of shaving so as to ensure immunity, has thus far 
failed to spread the disease in any case. 



742 DISEASES OF THE SKIN. 



Tinea jEmbricata. 

(Tokelau Ringworm ; Burmese Ringworm ; Bowditch Island Ring- 
worm; LafaTokelau; La Peta ; Cascadoe ; Herpes Desqua- 
mans. Fr., Herpes Tonsurans desquamatif ; Gune.j 

Tinea Imbricata is a contagious disease occurring chiefly in the tropics, charac- 
terized by the formation of concentric and scaling annular patches produced 
by a vegetable parasite. 

This disorder was first described by Fox, in 1844, and has since 
been studied by Turner, Manson, MacGregor, and Roux. One of 
the best clinical descriptions is given by Crocker. 

Symptoms. — The disease is first declared, after artificial inocula- 
tion, by a period of delay (" incubation ") lasting about nine days, 
after which minute reddish points appear, arranged for the most part 
in semicircles, the former rapidly developing to papules producing 
an intolerable pruritus. The growth thenceforward is reported to 
be at the rate of from five to ten millimetres each week. In a 
brief time lamellae of epidermis are detached, their free border directed 
to the centre of the circular disk; the patch or patches when fully 
developed being represented by concentric rings, about five milli- 
metres apart, suggesting a resemblance to " watered silk. 7 ' The 
scales may be as large as half a centimetre square, with curling 
edges which later become horny, and much darker in color. It is 
said that the hand passed over such patches from the circumference 
to the centre recognizes a smoothness in the surface ; but when the 
motion is reversed, from centre to periphery, the scales are raised 
and resist the fingers. The appearance of the older patches suggests 
a skin covered with clay. The process of production of the con- 
centric rings is reported to be, first, by the elevation of a central 
point of the epidermis, and the formation there by the fungus of a 
brownish mass ; then, separation of the epidermis at the central 
point, with persistence for a time of attachments at the border; liber- 
ation of the attached edge by friction or otherwise ; and the exposure 
of the corium. Just beyond this line a brownish rim declares the 
line of advance of the fungus beneath the epidermis. When the 
ring thus formed has attained a diameter of about five millimetres, 
a brown point again appears centrally, and there is a repetition of 
the process originally observed in the primary ring. 

All portions of the body may be affected ; but the scalp and face 
seem to be usually spared ; when the hairy parts (scalp, pubes, 
axillae) are involved, the disease spares the follicles ; and its manage- 
ment is thus declared to be correspondingly facile. Though the hairs 
themselves are not invaded, they are said to fall when the disease 
chances to extend over the hairy regions of the body. When the 
disease spontaneously disappears from any portion of the integument, 
there are left persistent, deep-colored rings or circles where the scal- 
ing originally occurred. 



PODELCOMA. 743 

Etiology. — The disease is always produced by contagion ; occurs at 
all ages and in both sexes, especially in children ; and is chiefly 
encountered in tropical climates. 

Pathology. — According to Koniger (who was not a dermatologist) 
and Manson, the disease is produced by a special fungus, the tinea 
imbricata, which invades the epidermis without involving the hair- 
follicles, its oval or rectangular spores more numerous than the myce- 
lium, while the threads are long, straight, and gently curved. It is 
not yet determined that the parasite is not a development of the tri- 
chophyton peculiar to certain tropical regions ; but Manson's state- 
ment, that inoculation of the same individual with both tinea imbricata 
and tinea trichophytina produces each disease separately, seems toler- 
ably conclusive on this point. 

The Diagnosis from " Giant Ringworm," " Boatman's Ringworm," 
" Dhabie's Itch," " Majee's Dad " — forms of trichophyton as it occurs 
in luxuriant vegetation upon the smooth portions of the body in 
tropical countries — is readily made. In the latter, the central area 
clears ; in the former, the central part of the patch is made up ot 
concentric rings. 

Treatment. — The scales are readily removed by soap and water or 
alkaline baths, and chrysarobin, pyrogallol, or iodine ointments are 
well rubbed into the part. In other cases, strong lotions are em- 
ployed of the same chemical constitution. 

The Prognosis is favorable. 



Podelcoma. 

(Madura Foot ; Mycetoma ; Fungous Foot of India ; Tubercular 
Disease of the Foot.) 

This is an endemic disease, affecting the feet or the hands, occurring chiefly in 
India, and probably due to a vegetable parasite. 

The disease occurs in two typical forms, the pale and the black ; 
and attacks generally the foot, though the hand, scrotum, and other 
parts also may be affected. Its beginning is insidious. The part 
becomes swollen, painless, and covered with pea-sized vesicles, bou- 
tons, or elevations, over which, in one variety of the disorder, are 
dispersed minute blackish granules. Each tubercle surmounts a 
sinus, from which, after bursting, is discharged a thin, sero-purulent 
fluid, containing granules, separate or aggregated in yellowish-brown 
mulberry-like masses. The swelling gradually increases, till the 
foot is a misshapen organ, riddled with sinuses which perforate 
periosteum and bone. These fistulous tracts discharge from time to 
time granules like poppy-seeds, caseous matters, or substances likened 
to blackish fish-roe. 

In mild cases, only a digit of either foot or hand may be implicated, 
with slight tumefaction ; in other cases the surface symptoms are 
predominantly of ecthymatous, furuncular, or carbuncular type, 



744 DISEASES OF THE SKIN. 

with single or multiple large centres from which the characteristic 
discharge occurs. The malady is chronic, lasting for years, the 
greatest deformity occurring either in the course of a few years or 
more, the entire duration of the disorder lasting even a quarter of a 
century. 

Etiology. — The disease is endemic in certain parts of India, whence 
it has one of its names, occurring at all ages, especially in male sub- 
jects who labor with bare feet on the soil. Traumatism of the foot 
or hand, probably offering a portal of access to the parasite, may be 
responsible for the onset of the disease. Some affected subjects have 
been the victims of filaria. 

Pathology. — The black masses resembling fish-roe recognized on 
section of a diseased foot, are found separated and aggregated in 
single and compound cavities, lined with a fibrous structure penetra- 
ting both superficially and deeply all the morbid tissues. Variations 
in color are recognized from black to reddish, pinkish, and grayish- 
yellow shades. These particles were recognized by Vandyke Carter 
as a fungus, to which his name was given, the Chionyphe Carteri, 
the difference in the color of the granules in different cases being 
due to the larger or smaller number of fungus elements in any case. 
Secondary changes are recognized in the direction of absorption and 
softenings or thickenings of invaded tissue, with caseous and fatty 
metamorphoses as ultimate results. The relations of the fungus to 
the " ray fungus " of actinomycosis are, by proper methods of stain- 
ing, fairly well recognized. 

Hewlett, of London {Lancet, 1892, No. 3592), describes mycetoma 
as an " actinomycosis of the foot"; and states that by Gram's 
method the so-called " fairy rings " of actinomycosis with delicate 
interlacing filaments are seen ; while staining with orange-rubin 
demonstrates typical " clubs " at the periphery. 

Diagnosis. — The distinction is to be established between actinomy- 
cosis, the guinea-worm disease, and Madura foot. The last is distin- 
guished by the special deformity of the foot or hand with peculiar 
blackish granules like poppy-seeds mingled with the discharge from 
the sinuses. 

The Treatment of the disease is by curetting all readily accessible 
and circumscribed depots of the fungus ; and, when the latter method 
is manifestly incapable of removing the morbid tissue, by amputation 
of a digit or entire limb. 

The Prognosis is not grave as regards life ; it relates solely to the 
deformity and uselessness of attacked members, which in most cases 
demand surgical interference in order to secure permanent relief 



ACTINOMYCOSIS OF THE SKIN. 745 

Actinomycosis of the Skin. 

Gr., auric, ray ; and jj-vkvQ, mushroom. 

(" Lumpy-jaw "; Aktinomykose. Fr., Actinomycose.) 

Actinomycosis is a parasitic disorder, occurring in man and in some of the lower 
animals, produced by the ray fungus. 

This disease was first recognized in 1887, as due to a parasite 
which Harz described, from its gross appearances, as the " ray 
fungus," occurring in the jaws of cattle. It has siuce been recog- 
nized in roan, and still later, by Majocchi, as of occurrence in the skin. 

Symptoms. — In actinomycosis the parasite usually effects entrance 
by the avenue of a carious tooth, and the skin, when implicated, is 
as a rule involved secondarily to other tissues. Such skin lesions are 
more often displayed about the face and neck, more particularly the 
lateral surfaces of the neck beneath the jaw, where deep subcutaneous 
tumors or swellings, livid in hue, thinning at one or several points 
after involvement of the integument, finally burst and give exit to a 
sero-sanguineous or bloody and purulent fluid, containing yellowish 
masses in which the fungus may be recognized. The orifices of the 
sinus or sinuses after such discharge are usually beset with cutaneous 
and subcutaneous nodules and uneven lumps, some softened, others 
firm and indurated, usually reddish or purplish in hue ; tender, 
painful, and often accompanied by pains elsewhere, particularly in 
mastication, in deglutition, and in certain movements of the head on 
the neck. 

The onset of the disease is insidious, and is said to occupy in 
caes months and even years. The nearer to complete evolution of 
the disease, the more rapid, as a rule, the development of its symp- 
toms. In exceptional cases the malady attacks the fingers, the hands, 
the nose, and other parts of the face. If the same parasite be effec- 
tive in the Madura foot (q. v.), as now seems probable, its sites of 
election must be correspondingly increased. 

Etiology. — As in mycetoma, more men than women are attacked 
as a result of special exposure ; some of the affected have been oc- 
cupied with cattle and horses ; others having carious teeth may have 
been infected by accidents of contact or by the operations of dentistry. 
My colleague, Dr. Murphy, had an interesting case in the person of 
a woman whose dog had died with a large swelling under the jaw. 
Several other cases have occurred in the city of Chicago, a few of 
the patients having been shown me ; all had submaxillary lesions 
and carious teeth. 

Pathology. — The parasite, actinomyces, or ray fungus, is visible to 
the naked eye in the form of opaque, yellowish-white grains, at times 
sulphur-yellow or even greenish-yellow in color, pin-head to split-pea 
sized, which, floating in a serous fluid, suggest at first sight caseous 
pus from a tuberculous abscess. Examined microscopically, these 
grains are found to be made up of delicately interwoven threads, 



746 DISEASES OF THE SKIN. 

single or dichotomously divided, radiating from a common centre 
and club-shaped at the terminus. The bulbus knobs are supposed 
to be the sporules, and the rays, mycelium of the fungus. The 
latter can be cultivated in nutrient media, with the result of produc- 
ing the disease in the lower animals after inoculation. 

Diagnosis — All supra-clavicular and submaxillary lesions consti- 
tuted of dark-reddish tumors or swellings, subcutaneous in origin, 
should be carefully differentiated from actinomycosis. Scrofulo- 
derma is to be recognized by the general condition of the patient 
(actinomycosis may occur in vigorous young adults) ; by the absence 
of pronounced lymphoma (" gomme scrofuleuse ") ; and by failure of 
recognition of the parasite, which is not easy of detection. The oc- 
cupation of the subject of the disease (as a farrier, stable-boy, or 
drover) may furnish a clew to the origin in some cases. Care 
should always be taken, in making a diagnosis, to exclude cases of 
swellings discharging pus, practically limited to the skin immediately 
over the lower jaw, with sinuses leading to the bone beneath, where 
the disorder is exclusively due to a carious fang of one of the lower 
central or canine teeth. All these may be relieved by the extraction 
of the offending tooth. 

The Treatment is by surgical procedures, erasion, antisepsis by the 
bichloride of mercury, boric acid, and dressings with antiseptic 
gauze. Gautier has employed with success an electro-chemical method 
of treatment, by the use of platinum needles and injections of a ten 
per cent, potassic iodide solution. Two needles are inserted, one 
connected with each pole of the battery, and a current of fifty 
milliamperes passed ; a few drops of the iodine solution are injected 
every moment during the flow of the electricity, the patient being 
anaesthetized. With the later views, however, entertained respecting 
the gravity of the disease, simpler measures may be employed with 
better advantage for most cases. 

Prognosis. — It was held, till lately, that the prognosis was favor- 
able only in case of thorough and prompt removal of all the diseased 
tissue. In other cases a fatal result was anticipated. 

Schlange, however, at the late Congress of German Surgeons, 
called attention to the fact that of nearly two hundred patients 
under his observation (over one-half traced since the year 1886), forty 
were completely cured for more than two years ; and in eighty the 
disease remained limited to the head and neck. After thirteen years 
of involvement, one patient is still alive. All extensive operations 
for relief of the malady are now abandoned. Even actinomycosis of 
the lungs and viscera is susceptible of spontaneous recovery. In- 
testinal complications only are grave. Cases apparently hopeless 
have recovered in five and six years. 



TINEA VERSICOLOR. 747 



Tinea Versicolor. 



(Pityriasis Versicolor ; Dermatomycosis Furfuracea ; Mycosis 
Microsporina ; Chloasma. Ger., Kleienflechte.) 

Statistical frequency in America, 1.02. 

Tinea Versicolor is a cutaneous disease occurring chiefly upon the trunk, neck> 
and upper extremities of adults, characterized by irregularly reticulated 
macular lesions, yellowish or brownish in hue, over which the epidermis 
may exfoliate in delicate scales, owing to the presence of the microsporon 
furfur. 

Symptoms. — The eruption in this disorder occurs in the form of 
few or many, irregular, roundish, circumscribed or reticulated 
maculae, pin-head to small coin-sized, rarely occupying an area of 
the size of the palm or larger. In color it varies from the most 
delicate buff or fawn shade to a reddish, deep brown, and even 
blackish hue. The surface of each lesion, when closely inspected, is 
usually seen to be covered by furfuraceous scales. If the latter are not 
visible, slight erasion with the finger-nail or curette w T ill demonstrate 
the fact that the superficial layers of the stratum corneum are, in the 
site of each lesiou, readily separable from the tissues beneath. The 
eruption is most common upon the anterior surface of the thorax ; but it 
is also displayed upon the neck, the dorsum, the abdomen, and the other 
surfaces of the trunk, and the flexor aspects of the upper extremities 
(the hands only excepted). It is rarely seen upon the lower extrem- 
ities ; still more rarely on the face ; never on the hands and feet. 
The eruption is either unproductive of any sensation, or accompanied 
by a mild pruritus. Patients will usually declare, that after profuse 
sweating, bathing in warm water, or brisk friction of the surface, 
minute epidermal rolls separate from the affected area. The disease 
may linger for years upon the surface of the body. It has a special 
tendency in susceptible individuals to recur after removal. 

Exaggerated forms of the eruption are occasionally encountered. 
In a young married woman who had been the subject of the 
disease for many years, the entire trunk, the axilla?, groins, upper 
portion of the thighs, the neck to the level of the high collar 
worn, and the upper extremities to the wrists, were encased in 
a uniform sheet or cuirass of chocolate-tinted epidermis, in a condition 
of exfoliation in finger-nail sized lamellated flakes. Even in these 
extreme cases the tendency of the disease to avoid the surfaces ex- 
posed to the light is distinctly manifested. Unna 1 describes another 
anomalous feature of the disease, in which the maculations occur in 
anuular form with a clearing centre. Rarely, also, a very few irregu- 
larly distributed maculae may be seen as the sole evidences of the 
existence of the parasite. Thus a patient may exhibit a small coin- 
sized patch on the surface of the chest, another on the shoulder, and 
possibly a third over the deltoid region of one arm. These are 

1 Viertelj. f. Derm. u. Syph., 1880, Nos. 2 and 3. 



748 DISEASES OF THE SKIN. 

generally cases partially relieved of a more diffuse eruption. More 
commonly, the slightest manifestation of the malady is an irregular, 
vertically arranged, somewhat narrow band of lesions immediately 
over the sternum, and visible beneath the hairs of that region in the 
adult male, or upon the intermammary sulcus of women. The face, 
hands, palms, soles, hairs, hair-follicles, and nails, are usually exempt 
from the disease. 

Etiology. — The disease is produced by a vegetable mould discovered 
by Eichstedt, in 1846, to which Robin gave the name Microsporon 
furfur. In capabilities for contagion it is far inferior to the vegetable 
parasites already described, and illustrates well a point to which atten- 
tion has been already directed, viz., that all these fungi flourish only 
in soils suitable to their germination and fructification. Members of 
one family are said to communicate the disease occasionally, the one 
to the other ; and Lancereaux 1 reports that in this way he accidentally 
infected himself from scales collected for examination from a patient 
in hospital, and afterward unwittingly transmitted the affection to his 
wife. The author has had personal knowledge of few instances of 
such transmission. The disease occurs in both sexes, rarely before 
puberty and after middle life, and in persons of every social condi- 
tion, irrespective of personal cleanliness. It is exceedingly common, 
more so, indeed, than statistics are capable of demonstrating, inasmuch 
as hundreds are annually annoyed by it who never seek professional 
advice. In thousands of physical examinations made with a view to 
the enlistment of men in the United States service, as also of govern- 
ment pensioners, the disease is often recognized upon the persons of 
those who pay no attention to its presence. Being concealed by the 
clothing and unproductive of much discomfort, many persons endure 
its presence with complacency. 

By some it has been supposed that the fungus is particularly apt 
to select the chest of the phthisical as its habitat, a supposition doubt- 
less based upon the fact that tuberculous men and women, more than 
all others, expose the chest to the view of the medical man in order to 
permit of its auscultation and percussion. 

Pathology. — The microsporon furfur is readily recognized by the 
aid of the microscope, as it exists in luxuriant profusion upon every 
affected surface. The scales may be scraped from the skin, and at 
once examined, when innumerable clustered spores and short threads 
become visible ; the former highly refractive and resembling in their 
circular and oval contours, droplets of oil. Their aggregation in 
clusters is distinctive of this among the other forms of cryptogamic 
vegetation. They measure 0.0023 to 0.0084 mm., while the hypha? 
vary in diameter from 0.0015 to 0.0038 (Duhring). Among the 
latter, sporophores are distinguishable, with contained conidia and 
terminal elements emerging at one extremity or the other of the 
spore-case. Both elements are more readily stained by eosine and 
methyl-violet than those of the trichophyton or of favus. 

1 Traite d'Anatomie Pathol., xi. p. 265, Paris, 1875. 



TINEA VERSICOLOR 



749 



One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter- 
esting mould. It never by any possibility invades the hairs or the 
hair-follicles, though it may be seen flourishing at the orifice of a 
follicular duct, and even beneath a vigorous pilary growth upon the 
chest of a male subject. It avoids the light and the air ; and singu- 
larly refuses to encroach even upon certain covered portions of the 
body, preferring, in its extreme development, to linger unobtrusively 
at the neck near the verge of the collar. 

Diagnosis. — Here, as in all the parasitic diseases of vegetable 
origin, the microscope may be required to decide the diagnosis in any 



Fig. 95. 



m 

Vrv 



4 

Microsporon furfur. (After Kaposi.) 



i < / > A 



case where doubt may arise. In its simpler manifestations, the 
recognition of the affection is very readily assured. The location of 
the eruption, its irregular reticulations, its characteristic, yellowish or 
fawn-tinted shades of color due to the nature of the fungus; and the 
exfoliation of the epidermis which it excites by its superficial pene- 
tration of the outer layer of the stratum corneum, producing thus a 
mealy, branny, flaky, or roll-like exuvium ; all this is significant. 
None of the chloasmata due to pigment changes in the skin, however 
much they may resemble tinea versicolor in color, share with it this 
peculiarity of desquamation. Chloasma may involve, moreover, the 
face ; tinea versicolor almost never. Vitiligo may occur upon the 
scalp ; tinea versicolor very rarely. The macular syphiloderm may 
be mistaken for the disease under consideration, but when developed 
to such an extent as to rival tinea versicolor in its diffuseness, the 



750 DISEASES OF THE SKIN. 

syphiloderm will creep out over the face, the hands, and the feet ; 
and will be accompanied by adenopathy, alopecia, mucous patches, 
palatine hyperemia, or furnish evidence of a polymorphic tendency. 
Often, indeed, with such an eruption, the survival of the initial 
sclerosis will at once betray the nature of the disease. These are 
important considerations, since in the mere matter of subjective sensa- 
tion, color, shape, and size of lesion, there may be marked resemblance 
between the two. The author has treated several patients with tinea 
versicolor who were suffering from syphilis, and many having the 
former disease who, from the fact of exposure, believed they also were 
infected by the latter, and yet indeed were not. These incidents 
serve to illustrate the importance of making an accurate diagnosis in 
every case of cutaneous disease. 

The most vulgar error, however, committed in this connection, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor, and either the liver itself, or the color changes which 
disease of that viscus is capable of producing in the skin. The exist- 
ence of " liver-colored " spots in the skin is hence erroneously 
attributed to hepatic disease. A remarkably comely, healthy-looking 
woman, of high social standing, who had been vainly treated for two 
years by internal remedies addressed to the liver, once consulted the 
author, with a view to the removal of large patches of tinea versi- 
color from the surface of the chest. She was completely relieved of 
her disfigurement in a week by the employment of local measures 
alone. Few patients consult their physician for the relief of this dis- 
order who have not a prejudice of similar sort. 

Treatment. — The author has always employed a single method of 
relieving tinea versicolor, for the simple reason that that one has been 
invariably successful. It is practically that given by Tilbury Fox, 
and requires merely vigorous and intelligent co-operation on the part 
of the patient. A hot bath is taken, if possible, for three nights in 
succession, and when the surface is well macerated by the hot water, 
the affected skin is resolutely scrubbed, either with the cheap yellow 
soap of the shops, or sapo viridis in substance or tincture. When 
the disease is extensively developed, this process is aided by friction 
with the flesh-brush or a coarse towel. The skin is then washed 
clean with a surplus of hot water, the patient still remaining in the 
bath, after which the affected patch is first moistened with vinegar 
and water, or dilute acetic acid, and afterward well sponged with a 
solution of the sodium hyposulphite, one drachm (4.) to the ounce 
(32.) being usually sufficient. As a rule, the last vestiges of the 
eruption are removed with the third bathing. Should there be 
recrudescence in isolated patches, as is often the case, or outlying 
areas which have withstood the parasiticide employed, these should 
be subsequently attacked with a solution of the corrosive chloride of 
mercury, one to two grains (0.066-0.133) to the ounce (32.). Other 
measures, however, are popular with physicians, and among them 
may be named the topical use of boric, carbolic, or sulphurous 
acid ; the tincture of iodine ; sulphur in bath, ointment, or lotion ; 



ERYTHRASMA. 751 

calomel in ointment ; the alkalies in bath or lotion ; sulphide of 
potassium in bath ; chrysarobin, pyrogallol, tar, Wilkinson's salve, 
and the other parasiticides employed in the treatment of ringworm of 
the body. The inner clothing should not be worn after treatment, 
till it has been immersed in boiling water. 
The following formula also is recommended : 



R. Hydrarg. chlor. corros. j$y, 133 

Saponis viridis 31J ; 64 

Spts. vin. rectif. ^iv; 128 

01. lavandul. f!?i: 4 



M. 

[Anderson.] 



Prognosis. — The disease can be readily relieved by simple treat- 
ment. Relapses often occur, and require to be radically treated. 
Untreated, the disease may continue for years without the slightest 
impairment of the general health. It is probable that when untreated, 
the parasite undergoes spontaneous exfoliation in advanced years, a 
period when presumably the fungus fails to find in the epidermis the 
nutriment upon which it thrives. 

Myringomycosis. 

The spores of the aspergillus, being conveyed to the external 
ear, occasionally develop there, especially if they come in contact 
with fatty substances introduced for medicinal purposes. Whitish 
masses can then be recognized in the canal, covered with greenish, 
brownish, or blackish spots. There is usually some deafness, with a 
sensation of ringing in the ears, and at times a thin serous discharge 
from the external auditory meatus. Lowenberg 1 recommends the 
injection of dilute alcohol into the canal for the destruction of the 
mould. 

Erythrasma. 

Gr., epvdpdg, red. 

Erythrasma is a cutaneous disorder, affecting chiefly those regions of the body 
where surfaces of the skin are in contact, characterized by erythematous, 
rosette-shaped maculations, and due to the presence of the microsporon minu- 
tissimum. 

Burckhardt first described this disorder in 1869, but it received its 
name from v. Barensprung in 1862. It has since been carefully 
studied and described by Balzer, Riehl, Koebner, Pick, and others. 

Symptoms. — The disease first appears in punctiform to palm-sized, 
roundish, definitely circumscribed maculations, presenting a sharp 
contrast in color with that of the adjacent integument. This hue 
varies somewhat according to the location of the patches. The 
younger lesions may exhibit a vivid redness over the entire maculae, 
or over their borders only. The older exhibit a yellowish or 

1 Gaz. hebd. de Med de Paris, 1880, 2me ser. xvii. p. 579. 



752 



DISEASES OF THE SKIN. 



brownish tinge. These colors are compounds of ordinary erythe- 
matous redness and yellowish or brownish discoloration of the horny 
layer of the epidermis. 

The maculae are circular, or rosette-shaped, or display very irreg- 
ular outlines. They are not raised above the general level of the 
skin to any extent, though the finger passed over the surface can 
recognize a slight elevation of the border due to hyperemia and sub- 
sequent moderate, fine flour-like, furfuraceous desquamation, most 
conspicuous also at the periphery. Vesiculation and papulation do 
not occur. The colors recognized in different patches may be light 
reddish-brown, pale reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered where apposed surfaces 
of the skin come in contact, such as in the axillae, the groins, the 

Fig. 96. 




Microsporon minutissimum, from patches of erythrasma. 



cleft of the anus, and the regions where the scrotum touches the thigh. 
I have, however, seen it in typical expression on the sides of the 
chest. The eruption spreads very slowly and in serpiginous outline 
until the affected surfaces are completely invaded. It is much more 
chronic in its course than the other dermato-mycoses, lasting for 
months and years without apparent change. 

Etiology. — Erythrasma is produced by the growth, in the superficial 
layers of the epidermis, of the fungus described below. Men are 
much more often affected than women ; children not at all. The 
youngest patient whose case is recorded was sixteen years old ; the 
oldest, fifty-five. 

Pathology. — The fungus termed microsporon minutissimum, to 
which the disease is attributed, is chiefly remarkable for the extra- 
ordinary delicacy and fineness of its threads and very minute spores. 



ERYTHRASMA. 753 

The former are either simple cylindrical bodies of variable sizes; or 
may exhibit partition septa ; they may divide dichotomously ; and 
may terminate in hooked or knobbed expansions. They are inex- 
tricably interwoven when occurring in large masses. The largest 
transverse diameter is 0.6 of a micromillimetre ; in length, the my- 
celium presents the greatest variation. Bacteria and heaps of zooglcea 
are visible among the scales. The granules are piled into irregular 
heaps according to Burckhardt, and give a dusty appearance to the 
epidermal cells on which they lie; often the outline of these granules 
is indistinct. According to the same observer, the breadth of the 
hyphse is j^Vo mm v an d the length from y 1 - to -^to mm - 

Pasquale de Michele [Ann. de Derm, et de Syph., 1891, p. 776) has 
discovered the leptothrix in cases of supposed erythrasma ; and this 
is but another of the proofs that in all diseases of this class, as in 
so-called eczema marginatum, there are few instances in which a 
single mould fungus develops on the bodily surface. The entire 
flora dermatologica, of Unna, may be effective in more cases than 
is commonly estimated. 

Diagnosis. — From all ordinary chloasmata and pigment maculae, 
the spots of erythrasma are distinguishable by the ease with which 
the superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater diffi- 
culty ; but the latter occurs in different situations by preference ; its 
patches are more vividly red ; and the parasite, under the microscope, 
presents distinctive features. 

The Treatment is that of tinea versicolor ; and the prognosis favor- 
able, subject to the disappointments arising from frequent relapses. 

La Perleche. — Under this title, Dr. Justin Lemaistre, of 
Limoges, 1 describes a contagious disease observed by himself in 
more than three hundred children of his city. It is characterized 
by dryness, smarting, cracking, and excoriation of the lips, the epi- 
thelium of which becomes blanched, macerated, and readily detached. 
Hemorrhagic and painful fissures form in the direction of the com- 
missural folds. Often plaques are visible suggesting mucous patches. 
The disease lasts for from fifteen days to a month, with possible 
recurrences which may lead to a year's suffering. 

The disease is supposed to be of parasitic origin, communicated by 
drinking from cups used by infected persons. The author attributes 
the disease to a streptococcus plicatilis which he has cultivated in 
Pasteur flasks. The microbes were originally found on the borders 
of epithelial cells of the lips of infected children. The parasite lives 
in the form of a micrococcus in stagnant water, wells, and springs. 
The disease is one of uncleanliness, and is readily prevented by appro- 
priate hygiene. 

1 Le Progres Medical, October, 1884. 
48 



754 DISEASES OF THE SKIN. 

Pinta Disease. 
(Spotted Sickness ; Mai de los Pintos.) 

This is a disease occurring in the tropics, supposed to be due to a vegetable 
parasite. 

The disorder thus Darned, described by Hirsch, 1 Iryz, and others, 
occurs chiefly in the tropical portions of South America. Its lesions 
are variously colored, shaped, and sized patches, increasing by cen- 
trifugal extension, over the face, extremities, and in general, except 
the palms and soles, upon regions exposed to the air. The hue of 
the patches varies from a grayish-white to a deeply pigmented shade, 
differing with different individuals and also exhibiting various shades 
upon one affected subject. The scales which are formed over the 
patches are of pityriasic type, larger in extreme cases. The hairs 
are reported to be changed in color and to fall from their pouches. 
Ulceration is a complication of the severer forms of the disease. 
The affected surfaces are intensely pruritic. 

In some patients a bluish color characterizes the affected parts, 
which in spots suggests a tattooing with dark powder. The disease is 
reported to last for months or years. It occurs at all ages and in 
both sexes ; is more common among the poorer and neglected classes ; 
and is rarer among the whites. 

The fungus supposed to produce the disorder, consists of mycelial 
threads bearing conidia, and rounded or oval spores. It is, like the 
other mould fungi, limited in its habitat to the epidermis ; and as 
respects treatment, yields to the parasiticides employed for the relief 
of other diseases of the same class. 



2. Animal. 
Scabies. 

Lat., scabere, to scratch. 

(" The Itch." Fr., Gale ; Ger., Kratze.) 

Statistical frequency in America, 2.58. 

Scabies is a contagious cutaneous affection, characterized particularly by the for- 
mation of a cuniculus, or furrow, produced by the acarus scabiei which is the 
cause of the disease, as also by the occurrence of several of the elementary 
lesions of the skin, accompanied by itching. 

Symptoms. — Scabies is a disease of polymorphic symptoms, which 
may be viewed as an artificial eczema or dermatitis, produced by the 
invasion of the itch mite. According to the extent to which the 
skin is primarily invaded by the parasite, or secondarily injured by 

1 Loc. cit. 



SCABIES. 755 

the traumatism which follows severe scratching of its surface, will 
its objective symptoms differ. 

Prominent among the latter is the cuniculus, or acarian furrow, 
an elongated gallery excavated in the epidermis by the female acarus 
soon after her impregnation by the male. The latter does not enter 
the skin, but is lodged beneath the crusts or other exuviae which 
gather upon its surface. This cuniculus, or furrow, is a whitish or 
yellowish, slightly arciform, linear lesion, with regular parallel bor- 
ders covered with dots or specks of blackish aspect, representing 
feces of the mite. It terminates at the upper extremity, by a vesicle, 
pustule, or exfoliation of the surface at the site of an infundibuliform 
depression ; aud at the deeper extremity, by a whitish and yellowish, 
shining and salient point, representing always the acarus. This is 
the most characteristic symptom of scabies. 

The "head " of the gallery is usually whitish, where the parasite 
first entered the skin ; aud is also more elevated than the " tail," 
where the acarus rests after laying its dozen or more of eggs. At 
times, the entire cuniculus forms an elevated ridge, rather than a 
thread-like depression, with white dots along its summit. When 
the roof of the vesicle at " the head " is torn off by scratching, the 
effect is to produce a reddened spot at its site, surrounded by a 
whitish moat running around the spot to the entrance of the gallery. 

When the burrow exists it can be most perfectly recognized in the 
interdigital spaces and on the skin of the penis, as a tangential line, 
running from a vesicle, papule, or pustule, to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellowish 
or blackish thread, the color being more pronounced in comparison 
with a fresh colored and washed skin, and less marked in contrast 
with a soiled surface ; being, in a soiled and subsequently washed 
integument, most conspicuous in proportion as the small puncta have 
served to entrap particles of dirt. The cuniculus may be curved, 
angular, or tortuous ; and occasionally may be seen well-nigh com- 
pletely covered by a bulla, pustule, or vesicle extending its entire 
length. In such cases, however, the female always penetrates beyond 
the peripheral wall of such lesion, working her gallery beyond it and 
more deeply, lest she be lifted by the exudation out of reach of the 
succulent rete where she feeds. 

Hebra points to the fact that between two parallels, one drawn 
through the nipples, and another at a short distance above the knees, 
on the anterior face of the body, can be recognized the greater part 
of the eruptive lesions in every case of scabies. 

The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 
in both sexes. As a matter of accident, it may appear, however 
rarely, in individuals of high social station. It is much more common 
in Scotland, Austria, Prussia, Sweden, Norway, France, and the 
Orient, than in this country. During the late civil war, it prevailed 
with relative frequency among the masses of Americans associated 
in regiments with foreigners who had been but a short time in the 



756 



DISEASES OF THE SKIN", 



country ; and steadily decreased after that time. But few cases 
were till lately seen annually in the public clinics of our large cities, 
though here and there, chiefly among newly arrived immigrants, 
isolated u nests " of the disease were discovered. The later influx of 
immigrants to this country (notably the Columbian Exposition of 
1893) has, however, in the last few years, again brought the disease 
into prominence by reason of its greatly increased frequency. 

In consequence of the irritation produced by the parasite and the 
traumatisms of scratching this furrow, all the symptoms of acute and 

Fig. 97. 




Female acarus, fecundated ; ventral surface. An ovum arrived at maturity is visible 
within the body. (After Kaposi.) 

chronic eczema are presented in the region invaded. These are vesi- 
cles, pustules, wheals, small papules, hyperemia of the skin upon 
which these rest, crusts formed by dried serum, pus, and blood, exco- 
riations, fissures, and, in cases of long standing, pigmentation of the 
skin where the disease has existed. These lesions may coexist, several 
appearing at the same time upon the skin of an affected individual j 
small vesicles and pustules, with perhaps a few short cuniculi visible 
upon their summits ; excoriations ; larger and longer cuniculi inter- 



SCABIES. 



757 



spersed^between inflammatory papules ; a tumid skin, evidently the 
seat of a mild grade of dermatitis ; and crusts here and there, beneath 



Fig. 







Acarian furrow, from the lumbar region. The female acarus is visible at the terminal 
extremity of the furrow with ventral surface exposed, and containing a mature ovum; two 
ova, next her, have been laid during the day ; the third exhibits traces of the embryo ; 
the twelfth exhibits a mature larva (a) ; twelve empty shells are also seen ; between these 
the feces are represented by black points. (After Kaposi.) 

which male and young acari are ensconced. Such is the composite 
picture of a typical eruption in scabies. 

It will be remembered that the acarus family find nutriment, 



758 



DISEASES OF THE SKIN. 



shelter, and all they require on the person of the individual whose 
skin they inhabit ; and there is no inducement for them to colonize 
at the instant of the first opportunity offered. The transfer of a 
male acarus alone, from one person to another, would not insure a 
generation of the young ; and the unimpregnated female could not 
alone do more. As for the impregnated female, Hebra, on several 
occasions, failed to induce scabies when one such only was transferred 
intentionally to a sound skin and seen to penetrate it. Lastly, the 
eggs alone would not suffice, for these have to be nicely planted within 
the epidermis, in order to be hatched safely to maturity. In brief, 
only the more intimate contacts of the bed at night, and the applica- 
tion of nails charged with acari of both sexes, especially the young, 
are to be regarded as most effective for the transmission of the disease. 
This explains why nearly seven men are found to be affected 
with scabies to one woman. Women are, as a rule, more inclined 
to sleep alone, or with those only to whom they have family ties ; 
while laborers, boys, apprentices, and persons of that class, including 
those who are strangers to each other, at times occupy the same beds, 
especially in the large cities, where they are often huddled together at 
night like swine. 

The intruder may be recognized always by the terminal extremity 
of her gallery, for it is now known that she does not in her lifetime 
leave it for any purpose, as was at one time taught. The female 
acarus here shows as a minute, whitish, clearly defined dot, present- 
ing a contrast in this particular with the blackish feces in the gallery 
behind ; and may be, in a good light, by a person of some dexterity 
and fair eyesight, extracted on the point of a cambric needle, from 
her lodging-point. It is important to know that this parasite may 
be recognized by the unaided human eye. Its characteristic tortoise- 
like body exhibits most of its anatomical peculiarities under a glass 
enlarging the figure but one hundred diameters. 

The regions affected by the eruption are the palms (especially of 
women and children) and dorsal surfaces of the hands ; the flexor 
aspects of the wrist-joints ; the sides and roots of the fingers and 
toes ; the feet (and, especially in women, the delicate skin of the feet 
near the instep, partly dorsal, partly plantar in situation) ; the but- 
tocks (more particularly in those who are seated in the trades and 
occupations of life) ; the extensor faces of the joints ; the belly, the 
penis and scrotum in men ; the anterior folds of the axillae ; the 
nipple and breast of women ; the elbows and knees, rather than the 
popliteal space and bend of the elbow ; and the anal region. Scabies, 
prurigo, and pruritus are alike in this, that in each the face and 
posterior aspect of the body display the fewest of any lesions visible. 
In general, portions of the body subjected to constant pressure by 
the clothing, as, for example, the regions pressed by the corset of the 
woman, and the waistband of the trousers in man, are sites of predi- 
lection. In other cases, the disease is encountered in the axillae, 
groins, and, as a matter of rare exception, over the entire surface of 
the body. 



SCABIES. 759 

The itching of scabies is occasionally severe, and has in fact con- 
ferred upon the disease its familiar English title, " the itch." This 
sensation is usually worse at night, when the parasite is rendered 
active by the heat of the body in bed, retained by the bed-clothing. 
It differs somewhat in different cases, being at times the cause of but 
little complaint. There is nothing characteristic, however, in the 
occurrence of this symptom, as equally severe pruritus accompanies 
ezcema unconnected with parasites. 

The itching which results from the epidermic tunnelling in progress 
is often noticeably more severe than would be suggested by the 
moderate number of skin lesions visible. When these lesions (puncta, 
vesicles, pustules, blebs, papules, resulting crusts, furrows, excoria- 
tions, etc.) are found upon the hands, the itching becomes so great that 
the infested person scratches also the accessible parts of the skin, 
where there were originally no acari, such as the inside of the thighs, 
the lower belly, etc., as Hebra suggests, simply because they are 
" handy." Hence it is that the picture comes to resemble that of all 
pruritic and scratched skins. 

Several artificial forms of this polymorphic affection are occasion- 
ally noted. In children, the face may become diseased after con- 
tact with the breast of the mother, or the buttocks after contact with 
the flexor aspect of the nurse's arm. Large vesicles, and even rupioid 
bullaB, may result from the irritation of their tender skins. Again 
in subjects predisposed to eczema for any reasous, the invasion of the 
parasite in one region of the body, possibly a region of preference, 
may originate an eczema in another locality whither the parasite has 
not wandered. In other cases, the most exaggerated forms of erup- 
tion are seen, usually in persons of filthy habits who have long suf- 
fered from the malady. Thus extensive epidermal callosities form, 
filled with debris of dead parasites unable to find nutriment longer 
in the cornified rete ; or extensive greenish and blackish crusts cover 
colonies of acari which survive beneath them for generations of their 
race. The nails in such extreme cases may be involved. The so- 
called Scabies Korvegica, or ^Norwegian itch, belongs without 
doubt to this class. As a rule, however, the disease does not advance 
to these severe grades. The parasites having gained lodgment in 
the skin, produce characteristic symptoms of the disease in the aver- 
age of cases, but even though unrecognized, and persisting for weeks, 
are the sources of so much annoyance that treatment of some sort is 
instituted which is apt to restrict the extension of the malady, cer- 
tainly in this country, within moderate limits. Usually after lodg- 
ment is effected, a week or fortnight elapses before the first character- 
istic furrow is formed, though the pruritus is of earlier occurrence. 
The extension of the disease by the maturing and ravages of young 
acari requires a few weeks more, so that in the course of from two to 
three months, the evolution of the malady may be considered as 
complete. In the course of about three months more, the disease, 
unchecked, may become generalized. 

Even the animal parasites elect the soil upon which they thrive, 



760 DISEASES OF THE SKIN. 

and indeed, after such election, thrive well or ill, according to the 
conditions present. This is not only exemplified in the matter of indi- 
vidual susceptibility, but in the conditions of health of an affected 
person. Thus in puerperal and typhoid fevers and other grave 
states of systemic disturbance, the parasites perish in the skin and 
the resulting eruption disappears ; classical symptoms recurring in 
convalescence if one or more acari have survived with sufficient vigor 
to reproduce their kind. 

Etiology. — The disease is produced only by the acarus scabiei (or 
sarcoptes scabiei) and is thus contagious, the parasite being introduced 
upon the surface of one individual, mediately or immediately from 
the skin of another infested man or an animal. All persons are 
supposed to be susceptible to the disease, but the difficulty of inten- 
tionally transmitting it by contagion is greater than that of inducing 
the leech to fasten itself indiscriminately upon any given skin. The 
brief shaking of the hand or transient personal contacts of the day- 
time are certainly in many cases quite insufficient for contagion. 
The author has repeatedly handled the skin of patients affected with 
scabies for half an hour at a time, always with impunity ; and few 
practitioners of medicine suffer after the most careful examination of a 
patient. When a case is exhibited at the clinic, it is minutely, and 
without ill results, examined by dozens of students. It is probable 
that the contacts of the night, incidental to the occupation of the 
same bed, or the use of gloves and other articles of apparel con- 
taining parasites or their ova, are essential to the transmission of the 
disease. 

Pathology. — The pathology of the eruption induced by the para- 
site is that of the various phases of exudation. The differences 
between scabies and all other eruptions of similar type, depend, in 
the case of the former, upon the peculiarities of the exciting cause 
of the disease. In the description of this, the acarus scabiei, I shall 
avail myself of the admirable chapter devoted to the subject by 
Kaposi. 

The female acarus, visible as a yellowish-white dot at the cul-de-sac 
of her subcutaneous gallery, and removed hence on the point of a 
fine needle, is visible to the naked eye, but best examined under the 
microscope. The body is oval, with a short projecting head and a 
convex dorsum transversely corrugated, with short spinous processes 
projecting for the most part backward, a direction largely followed 
also by the eight long bristles which are most noticeable at the posterior 
extremity of the trunk. The posterior portion of the dorsum also 
exhibits a series of recurved, short, hook-like projections, arranged 
circle-wise, about the ano- vaginal orifice. 

The flat ventral surface exhibits eight short claws or legs, four 
anterior and four posterior. The former are set near the head, and 
are provided each with hairs, and a long, pedunculated sucker. The 
latter are armed solely with long, straight bristles. All the eight 
have five articulations. The head is oval in shape, and provided 
with four pairs of mandibles and six palpi. There are two ventral 



SCABIES. 761 

outlets ; and a stomach, intestines, ovaries, muscles, and even mature 
ova can be recognized internally. 

The males are smaller than the females and fewer in number. 
They differ also in this, that the posterior extremities are provided 
with suckers and stalks, as are the anterior extremities of the female. 
Situated between these and the median line, is a horseshoe-shaped 
mass of chitin ensheathing a fork-shaped penis. They are said to 
die in the course of from six to eight days after copulation with the 
female. The latter survive from twenty to sixty days. 

The female alone, as already said, penetrates the epidermis. This 
act she accomplishes by inserting the head first into the tissues of the 
skin, the body disappearing afterward, and depositing behind, in the 
course of her progression downward, from one to two eggs daily till 
from twenty to fifty have been laid. These are oval, their longi- 
tudinal axes placed transversely to the cuniculus. In the two or 
three eggs found nearest the female, only a yellowish color can be 
distinguished ; in the third to the fifth, traces of the embryo are 
recognizable ; the sixth to the ninth contain larvae ; and, in the 
oldest, the head and front legs can be discerned. There are six of 
these extremities when all are developed. When mature, the shell 
of the ovum is ruptured, usually between the third and sixth day, 
and the young acarus reaches the surface of the skin, either by making 
exit at the original point of entry of the mother, or by the rupture 
of the roof of the burrow. It subsequently buries itself in the skin 
for a brief time, while the process of casting its slough is completed. 
There are three of these periods in its existence. Before the first is 
accomplished, the young acarus is provided with but two pairs of 
posterior extremities, two anal bristles, and ten dorsal spines. After 
the first, it is an octopod with four oval bristles and twelve dorsal 
spines. At the second, it gains two dorsal spines, and after the third, 
it possesses fourteen. The acarus survives but a few days when 
removed from the skin and immersed in liquids which protect it from 
the air, such as water, oil, etc. 

The transmission to man of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished ; but the colony 
under these circumstances rarely thrives. The same is true of the 
human acarus when transferred to the lower animals. 

Diagnosis. — The diagnosis of scabies must rest upon the recogni- 
tion of its special features described above. There are no lesions 
peculiar to the disease save the cuniculi, or furrows, made by the para- 
site, and these, it w T ill be remembered, do not appear till one or two 
weeks have elapsed after infestation. They may also be obliterated or 
concealed by excoriations when the finger-nails plough them open, or 
by pustulation, and subsequent crusting when the irritation induced 
is excessive. In every well-marked case, however, cuniculi can be 
discovered, if not on the fingers, wrists, or forearms, at least on the 
penis, the breast near the nipple, or some other covered portion of 
the body. With care and a little dexterity, a fine cambric needle can 
be then forced into the furrow well down to and a little beyond its 



762 



DISEASES OF THE SKIN. 



remote cul-de-sac, and the forts et origo malorum be thence extracted 
and placed under the objective of the microscope. 

Next to the cuniculus and its inmate or inmates, the two most 
important diagnostic features of scabies are the polymorphism of the 
eruption and the sites of its most frequent occurrence. Possibly the 
latter should be named first, as the more important of the two. Few 
skilled diagnosticians would fail to entertain a suspicion of scabies 
in a case of supposed " eczema/ 7 existing upon the fingers, wrists, 
and penis only, or on the breast of a mother, the face and buttocks 
of her infant, and the arms of its nurse. 

At the same time, it is a matter of great importance to remember 
that eczema is often attended with very severe itching; that this 
sensation may be intensely aggravated after retiring to bed at night ; 
is often limited to the hands ; is not rarely characterized by inter- 
digital vesicles and pustules ; and is, indeed, in this country very much 
the more frequently encountered of the two diseases. The vulgar 
conception of scabies holds to the belief that the disease is exceedingly 
common ; that every severe itching with a cutaneous exanthem is 
produced by " insects " or " worms " in the skin, and that transient 
casual contacts are abundantly capable of transmitting the offending 
parasite. Many more cases of simple eczema are supposed to be 
scabies than the reverse. There are few villages in the country which 
cannot lay claim to an " itch," often known by a name of local sig- 
nificance. Among these may be counted the so-called " prairie itch " 
of the West. These are, as a rule, forms of eczema quite unconnected 
with the existence of a parasite, and incurable generally by the para- 
siticides too often employed to " kill " the disease. In all such 
instances, the absence of the characteristic features of scabies described 
above, the absence of a history of contagion, and the presence of that 
of an alternating relief and aggravation of the symptoms, will point 
to the real character of the malady. 

In the severe pruritic affections of the West and Northwest, which 
the reader will find described in the chapter devoted to the several 
forms of pruritus, it is noticeable that the patients are often cleanly, 
those who are careful as to the hygiene of the body. Scabies is really 
a filth disease, and is best recognized among the filthy classes. Of 
diagnostic importance is the relative proportion in frequency of cases 
of scabies to all other cutaneous affections, pruritus included, observed 
in this country. 

From the year 1878 to 1882 the Statistical Committee of the 
American Dermatological Association reported 58,617 cases of skin 
diseases of all kinds, and the total number of cases of scabies included 
in the list was but 665, that is 1.10 per cent. The year 1883 to 
1884 was an exceptional one as regards scabies. Out of 9329 cases 
of cutaneous disease reported from Boston, New York, St. Louis, 
Chicago, and Canada, there were 339 cases of scabies. This rela- 
tively great increase was largely due to local causes, however ; for of 
these cases Boston reported 179, and accompanied these figures with 
a note calling attention to the increase. It is interesting to specify 



SCABIES. 763 

that of the cases collated in the year named, only 33 were seen in 
private practice, the remainder, 306, being observed in dispensary or 
public patients. 

During the succeeding year ending June 30, 1885, there were 442 
cases of scabies reported from the several districts, of which 49 
occurred in private, and 393 in public practice. This year, also, 
Boston exhibited the largest increase, reporting three more than one- 
half the entire number of cases of scabies registered in this country, 
viz., 224. Since these dates the disease has spread extensively in 
all our larger cities. The total for the years 1891 and 1892 ap- 
proximated 1000. 

Treatment. — The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the 
former has induced. Ordinarily the two indications are fulfilled at 
the same time. In such cases, the destruction of the parasite is 
followed by relief of the resulting cutaneous lesions ; and the skin, 
freed from the burrowing acari, is no longer tormented by the 
scratching which in extreme cases is not only irresistible but an 
important element in the aggravation of the lesions. In other cases, 
however, the resulting eczema or dermatitis persists after the removal 
of the original cause of the disease, and demands special attention. 
Care should always be had to avoid treating the delicate skin of the 
infant with the severer remedies efficacious upon the thicker integu- 
ment of the adult. 

Sulphur, in all its forms and in various combinations, has long 
held the highest esteem in the treatment of the disease. Other 
remedies, however, of acknowledged efficacy are employed with satis- 
factory results, most of them owing their usefulness to the strong 
odor which they emit. Among these may be named carbolic acid ; 
petroleum ; naphthol ; the oils of cloves, cinnamon, rosemary, and 
mint ; tar ; balsam of Peru and balsam of Tolu ; styrax ; staphy- 
sagria ; Vleminckx's solution, herotofore described ; and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, one to 
two drachms (4.-8.) to the ounce (32.), firmly, thoroughly, and care- 
fully rubbed, first into the affected patches, especially between the 
individual fingers (or toes), about the wrists, over the palm and 
dorsum of the hand, into the axillae, about the nipples, penis, but- 
tocks, or other invaded parts ; and finally over the cutaneous surface 
in general, the head alone excepted. If no severe eczematous com- 
plications exist, the inunction is well preceded by a warm soap, or 
soft soap and water bath. But in the event of such complication, the 
bath should be deferred as decidedly injurious in the inflamed con- 
dition of the skin. 

The first inunction is preferably performed at night, after which 
the patient retires to his bed enveloped in woollen underclothing, or 
wrapped in a blanket. It is neither wise nor necessary to induce 
sudation by these measures, for the skin is best retained in simply a 
greasy condition, unmacerated by sweat. In England it is customary 
to bathe on the ensuing morning, but it is preferable to defer the 



764 



DISEASES OF THE SKIN. 



latter till the cure is complete, however disagreeable the condition of 
the integument may be to the sufferer. The sulphur inunctions are 
thus repeated for three successive nights, a thorough warm soap and 
water bath being finally employed for the purpose of cleanliness. 
The clothing meantime should be either thoroughly disinfected with 
sulphur, immersed in boiling water, or subjected in a stove or furnace 
to a dry heat capable of destroying all acari and ova which may 
adhere to it. 

In France, the routine treatment of scabies is always preceded by 
a thorough friction for twenty minutes with soft soap, special atten- 
tion being as usual directed to the invaded areas. This is at once 
followed by a bath in warm water, during which the surface is also 
thoroughly scrubbed for from thirty minutes to an hour. Lastly, 
the parasiticide is well rubbed on for fifteen minutes, the patient 
re-dressed in the underclothing (disinfected during the progress of the 
bathing) and the final cleansing of the skin with water is practised 
within twenty-four hours. 

When a resulting eczema demands attention, it is to be treated in 
accordance with the general principles considered in the chapter 
devoted to that subject. In such case the dusting powders, the 
oleated lime-water, the zinc, diachylon, and even more stimulating 
ointments, may be employed with advantage. Generally, after a 
vigorous course of external treatment with surphur, the patient 
should be instructed to defer any further topical applications to the 
skin for a week or more, in order to test the efficacy of the method 
pursued. 

One of the following formulae may be substituted for the ordinary 
sulphur ointment : 



R . Sulphur, flor. 3 xij ; 

Potass, subcarb. % yj ; 

Adipis % ix ; 

Hardy's modification of Helmerich's ointment. 



j£ . Styracis liq. 
Petrolei \ 
01. olivse ) 
Balsam. Peruv. 
Spts. sapon. virid. 

R. Potass, sulphuret. 
Sapon. alb. 
01. oliv. 
01. thym. 



B. 



aaf ^ss; 
f^ijss; 

3xx; 
fgiv; 

gtt. xv ; 



3ss; 



Sulphur, sublim. 
Balsam. Peruv. 
Adipis ^ > ij; 

For use especially in the scabies of children. 



48 
24 

288 


M. 


4 




16 




10 
20 


M. 

[Kaposi.] 


20 

80 

16 

1 


M. 

[Jadelot] 


2 




32 


M. 

[Duhring.] 



Hebra's modification of Wilkinson's salve, Yleminckx's solution, 
and the balsam of Tolu are employed for the same purpose. 
Kaposi's naphthol formula is : 



ANIMAL PARASITES. 765 

H . Xaphthol. 15 parts ; 

Sapon. virid. 50 parts ; 

Cret. alb. pulv. 10 parts ; 

Axung. 100 parts. M. 

McCall Anderson much prefers, on account of its pleasant aroma : 

R: . Styracis liquid. ^ j ; 32 ( 

Adipis §ij; 64| M. 

Melt and strain. 

or Schultze's modification of Pastav's formula : 



R . Styracis liquid. f :§j ; 32 

Spts. rectificat. f^ ij ; 8 

01. olivse f 3j ; 4 
Ft. liniment. 



M. 



Prognosis — Scabies is an entirely curable disease, even after per- 
sistence for long periods of time. When, however, complications 
exist, or severe eczema continues after the efficient action of a para- 
siticide, the patient may experience some delay before attaining 
complete restoration to health. 

Demodex Folliculorum. 
(Steatozobn, or Acarus, Folliculorum. Gee., Haarsackmilbe.) 

This parasite was discovered by Henle, in 1841. It is a micro- 
scopic creature in the form of an elongated and jointed worm, with 
head separated from the thorax, and eight legs, four on a side, each 
with three articulations, and terminating in three small hooklets. 
The posterior extremity of the body is a vermiform appendage, 
terminating in a conical point. 

The demodex is found long after birth upon the free surface of 
the skin, those parts particularly where the sebaceous glands are 
large, and on patients affected with acne or seborrhcea oleosa, as well 
as upon those free from all evidence of disease. It is encountered 
also in the substance of the comedo plug, where at times from five to 
twenty may be discovered in a single follicle. It is, however, in no 
case the source of disease. A demodex, which is considered to be 
a variety of that discovered upon the skin of man, infests dogs, 
mice, and other lower animals ; and may be, in the latter, the source 
of disease characterized by furuncular lesions, abscess, and even fatal 
results. None of these parasites are, however, known to be trans- 
missible to man. 

Pulex Penetrans. 

(Rhynocoprion Penetrans, Sarcopsylla Westwood ; Nigua ; 
Chigoe ; Jigger.) 

The Sand-flea is a minute, brownish-red, egg-shaped parasite 
which penetrates the skin of man and of the lower animals, includ- 
ing rats and mice. It is encountered chiefly in tropical countries, but 



766 



DISEASES OF THE SKIN. 



Fig. 99. 



is said also to exist in higher latitudes, even in some of the southern 
of the United States. Fecundated females only attack the skin, in 
man usually about the toes or near the nails, entrance being effected 
with scarcely painful pricking sensations. In the course of from 
five to ten days a painful oedema with pustula- 
tion follows, occasionally accompanied by a lymph- 
angitis or severer symptoms in the form of gan- 
grenous abscesses. These sequelae are said to result 
from the distention of the ovary of the parasite, 
which may exceed fivefold the original dimensions 
of the insect. The treatment of the disease is the 
extraction of the flea by the aid of a heated needle, 
whereby it is simultaneously destroyed. The re- 
sulting wound may be cauterized or dressed anti- 
septically. 

Pulex Irritans. 

The Flea which specially attacks man, is a 
brownish-red insect, having a laterally compressed 
body, an oral haustellum, serrated soft mandibles, 
a tongue sheathed in an inferior labium, and a pair 
of labial, four-jointed palpi. Each of the triple 
segments of the thorax bears a pair of five-jointed, 
double-clawed legs. The male is 2 to 5 millimetres 
in length, and 1 to 2 in breadth, the female being 
nearly twice that size. The female deposits her eggs in any fissure, 
crevice, or fold of garment or furniture which may be accessible, from 
which the larvae are produced in a week. The nympha is enfolded in 
a cocoon, but only the mature insect preys upon man. According to 
Geber, it injects an irritating fluid into the skin at the moment of 
attack. The lesion it produces is a hsemorrhagic punctum, followed 
by a transitory hyperemia and a hsemorrhagic exudation which may 
persist for a few hours. 

The central punctum, or point, distinguishes the wound produced 
by the insect from macules of simple erythema ; but care should be 
taken when fever is present to exclude the symptomatic erythemata. 
The site of the wound may become an urticarial wheal. 

Mixed cases of flea-bites with wounds produced by bugs and lice 
are often seen in the lowest classes applying for relief to public chari- 
ties ; and the deeply pigmented skins they exhibit, often with purpuric 
lesions distributed over the lower extremities, if commingled with 
syphilitic eruptions, are in the highest degree confusing. The practi- 
tioner should always be on his guard in pronouncing on these cases, 
especially if the purpuric blotches occur in the cachectic and those 
suffering from other diseases than of the skin. 



Demodex follicu- 
lorum. 



ANIMAL PARASITES. 767 

Filaria Medinensis. 
(Dracunculus Medinensis; Filaria Sanguinis ; Guinea Worm.) 

This parasite is a nematoid worm, which, after invasion of the human body, 
induces a tumefaction of the skin which may result in an abscess and a dis- 
charge of the worm wholly or in part. 

Symptoms. — The lesions due to the invasion of the skin by the 
dracunculus medinensis, are first observed at the point where the 
worm is about to make exit, which may be at a considerable distance 
from that where it entered, and that after an interval of several 
weeks or months. This approach to the surface for the purpose of 
securing exit, is accomplished only when the worm is quite mature. 
After some local sensation of tension or itching, a pea- to small nut sized 
vesico-papule forms, superficial or subdermic in situation, which, 
after accidental or intentional rupture, gives exit to a clear serous 
fluid in which the uncolored head of the worm may be recognized. It 
is surrounded by a quantity of leucocytes and appears either at once 
or in the course of a brief time, producing slow and sinuous move- 
ments by alternate contractions and elongations. The entire worm 
and its young may then be wholly extruded in the course of a 'week 
or more; or the head may be withdrawn and another swelling 
form at another part of the surface, the first meantime closing ; or, 
in badly managed cases, the worm may be torn so that the head only 
is removed, and then a severe lymphangitis with inflammatory, sup- 
purative, and even gangrenous symptoms may supervene, producing, 
in fact, the train of symptoms now well recognized in connection 
with septicaemia. 

In some cases, however, the body may be discharged later than 
the head, after the mechanical separation of the latter, without serious 
consequences. The escape of embryos into the adjacent tissue is also 
regarded as a grave complication. 

The chief sites of exit are the foot — particularly the heel — the 
leg, thigh, buttocks, scrotum, hands, trunk, neck, and face. There is 
usually but one worm in a single subject of the disease, but the 
number may be indefinitely large in persons exposed. 

Etiology. — The disease is produced by ingestion of Avater contain- 
ing the larvae of the parasite. Though denied, it seems highly 
probable that it may also obtain access by a traumatism inflicted at 
a date prior to that of invasion. The fact that nearly two-thirds of 
all cases occur in the foot is not without significance. Young 
filariae have been seen in fresh water penetrating the microscopic 
crustacese, whose later ingestion with water is supposed to be effective 
in the production of the disease. 

The disease is endemic in India, Arabia, and Persia ; in Egypt, 
Africa, and portions of South America, it is also found, but with 
greater rarity. 



768 DISEASES OF THE SKIN. 

Mauson 1 believes that the parent filaria inhabits the lymphatic 
trunks, and reports a case of lymph-scrotum in which a long slender 
worm, resembling catgut in appearance and of the thickness of a 
medium-sized horsehair, was found filled with embryos in different 
stages of development. After the removal of about two inches of 
the parasite, the worm was broken. It has also been recognized in 
the sac of the tunica vaginalis affected with hydrocele. 

The mosquito is said to act as a carrier ; sucking the filaria with 
the blood of an affected person, it afterward deposits the ova or 
embryos, which have meantime hatched, in the water where it lays 
its own eggs. These embryos are then swallowed with the drinking- 
water by another victim ; and so the cycle of disease is completed. 
It is a nocturnal parasite. During the day the nlarise lie dormant at 
some point in the victim's circulation, but at evening they sally forth 
and rove the current of the blood the night long. 

Pathology. — The female alone invades the human body ; and is a 
filiform and uniformly cylindrical body from three to four metres 
long and one or two millimetres in thickness. The head is convex, 
with a central oral orifice surrounded by four papilla?. It is vivipa- 
rous, the embryos numbering millions and measuring 0.05 in length, 
and 0.02 in thickness, with a head somewhat thicker than the body, 
no buccal orifice, and a pointed tail. In from ten months to a 
maximum of fifteen the maturity of the female which has been 
impregnated is attained, and the parasite finds its way from muscles 
or other tissue in which she has been lodged or to which she has 
travelled, to the surface of the body. 

The Diagnosis (to be made in countries where the disease is 
endemic) is based upon the discovery of the worm. 

Treatment. — The usual method of treatment by the natives is to 
carefully secure the head when it appears, and to wind out the worm 
very gently day after day, till the entire body is extracted, securing 
the accessible portion by winding it about a bit of stick or paper. 
Continuous irrigation of the wound is both recommended and prac- 
tised where the disease is common. The tincture of asafcetida has 
also been employed to destroy the parasite. 

Forbes Dick 2 describes the four methods chiefly employed for the 
purpose of obtaining relief, as operating on the principle, either to 
" stink, coax, suck, or pull the worm out." The first is usually 
accomplished by the aid of asafcetida poultices, and is the least de- 
sirable of all. A combination of the others is preferred, the warmth, 
moisture, and protection afforded by the poultice first attracting the 
worm to the surface. When this result is obtained, an incision is 
made, and usually a foot or more of the worm is at once liberated. 
According to Dick, when the worm can be felt at two or more places, 
the point for incision is at the third part of its anterior extremity, 
which is always furthest from the heart of the patient. After this 
the worm is carefully wound about an aneurismal needle or similar 

1 Lancet, 1880, p. 10. 2 British Medical Journal, 1880, p. 207. 



ANIMAL PARASITES. 769 

implement, and traction very gently made upon it for from ten to 
fifteen hours. If it cease to yield to this force the traction should 
never be increased, lest the parasite seize the adjacent tissues with its 
mouth. Suction by the natives is accomplished through trumpet- 
shaped tubes. 

The Prognosis is favorable, save in cases where septicemic symp- 
toms develop as a consequence of coccogenous infection. 

Craw-Craw. 

(" Papulose Filakiexxe.") This rare affection was Originally 
described by Silva Aranjo, in 1875. It has since been studied by 
Nielly {Bull, de V Acad, de MSd. de Paris, 1882, p. 395), O'Neill, 
Man son, and others. 

It occurs only on the West Coast of Africa, chiefly among the 
negroes in whom papules, vesicles, pustules, and vesico-pustules 
appear as single, multiple, and desseminated or grouped lesions 
accompanied with severe pruritus. The scratching of the affected 
parts is excessive, and the crusting at times a prominent feature of 
the disorder. As a whole the disease assumes an inflammatory 
aspect and is superficial in situation. The regions involved are the 
arms, forearms and hands, feet aud legs, and several portions of the 
trunk. 

By removal of the crusts and erasion of the soft tissue beneath, it 
is said that in some cases the disease has been brought to an end. 
Other observers, after removal with a knife of the apex of some 
lesions, have recognized a nematode filarial parasite, displayiug two 
blackish points near the head which are said to distinguish it from 
the filaria medinensis. The parasite of Craw-Craw is apparently 
related to the latter, and is supposed to belong to the family of the 
anguillulidse or anguillulse, a class of parasites discovered in some 
portions of Europe among the lower animals. 

Cysticercus Cellulosae Cutis. 

Cysticerci have been recognized in the skin and subcutaneous 
tissues by Rokitansky, Lewin, Guttmanu, Schiff, Ferreol, Duguet, 
and other observers. In such cases, one or many roundish, firm, 
elastic, cutaneous or subcutaneous, pea- to walnut-sized tumors, isolated 
or disseminated, unproductive of pain, project from the general level, 
and are enveloped by an unaltered integument. They occur upon 
the truuk and extremities. ' They may remain in this condition with- 
out change for years ; and may accompany cysticerci of the brain and 
other portions of the body, productive of the serious disturbance of 
the economy which such invasion may determine. If the skin 
tumors be opened and their contents examined, the parasite will be 
recognized as an ampulliform sac, with a cephalic appendage, reen- 
trant or projecting, and provided with four suckers aud a coronal of 
hooklets. By no external characteristics could such tumors be dis- 

■ 49 



770 DISEASES OF THE SKIN. 

tinguished from others of similar size and external appearance. 
Only in the rare case of nervous complication could a suspicion arise 
based upon the real character of the disorder. ^Respecting this 
matter, however, the diagnostician is in no worse position than when 
called upon to recognize cysticerci of the viscera. Cysticerci of the 
liver are distinguished during life, and subsequently removed by 
operative procedures. 

The diagnosis is from gumma, lipoma, epithelioma, and sarcoma. 
The first occurs only in the syphilitic ; the second has a peculiarly 
uneven surface and firm feeling ; the third is largely facial in situa- 
tion ; and the last is of a plainly malignant character and relatively 
rapid career. 

Echinococcus. 

Weyl and Geber state that this parasite, not mentioned in derma- 
tological treatises, is found often in the human skin. Of 336 cases 
reported by Davaine, the parasite occurred thirty times in muscular 
and subcutaneous tissues, more often in women than in men. The 
softish, fluctuating tumors or vesicles produce a disagreeable sensa- 
tion of tension, and undergo fatty or other metamorphosis after the 
death of the encapsulated parasite, which usually occurs in from one 
to two years. Exploration of the superficially seated fluctuating 
tumor, covered by unaltered integument, usually demonstrates its 
nature. 

Distoma Hepaticum. 

Ktichenmeister (loc. cit.) reports three instances in which the embryos 
of the large liver fluke were encapsulated in subcutaneous tissue. 
The tumors were painful or painless, and occurred on the head, trunk 
and extremities. 

Leptus. 

(Leptus Autumnalis ; Harvest Bug ; Mower's Mite. Fr., Rouget.) 

This is a minute, reddish, or yellowish-red insect of the family of 
the trombidae, visible to the naked eye, and found in summer and 
autumn clinging to bushes and grasses. It is found both in this 
country and in Europe. It attacks man only after its accidental 
location upon the skin, where it perishes in the course of a few hours. 
In such situations, however, it induces considerable irritation, betrayed 
in erythematous, urticarial, papular, and even eczematous symptoms, 
accompanied by pruritus of various grades. The parts chiefly 
affected are the ankles, legs, arms, and feet. It may be seen in the 
skin as an orange-reddish or brick-reddish point, which represents 
often the body of the insect, its head being buried in the aperture of 
a follicle beneath. Examined after extraction, it is seen to have a 
relatively large cephalic extremity. It has a short, cylindrical, and 
conical haustellum, composed of fused double maxillse ; and two 



ANIMAL PARASITES 



771 



strong, hooked, five-jointed palpi, which can be rolled up. There 
are also two hatchet-like mandibles. It has a well-rounded or oval 
body 0.3558 mm. long, and 0.32 mm. broad, provided with three pairs 
of legs. It is found upon the lower limbs particularly, but also upon 
the scalp and every other part of the body. According to Duhring, 



Fig. 100. 




Leptus. (After Kuchenmeister.) 



Fig. 101. 




Leptus autumnalis (harvest bug). 



Fig. 102. 




Acarus hordei. 



children are particularly liable to its encroachments. The disorder 
is relieved by the application of a little balsam of Peru in olive oil, 
carbolated oil, spirit of camphor, or other mild stimulant or parasi- 
ticide. 

There are several species of leptus (leptus Americanus, leptus 
irritans) and other insects living on shrubs and grasses which, 
especially in the months of August and July, attack the human skin. 



772 DISEASES OF THE SKIN. 

The Acarus Hordei (Krithoptes monunguiculosus) is Darned by 
Weyl and Geber as the larva of a mite that annoys laborers in 
barley. It is yellowish-white, oblong or oval in form, averaging 
0.022 mm. in length. There is a protrudible tubular haustellum, 
enclosed by serrated mandibles. On each side are five-jointed palpi. 
There are four pairs of feet : two on the cephalo-thorax ; two, 
abdominal in situation ; all articulated to the epimeres. The tarsus 
of the first pair terminates in hooked claws ; the others havehaustel- 
lum disks on stems. Between the first and second pairs are swinging 
clubs, indicating the larval condition. 

Dipterous Larvae in and beneath the Human Skin. 

There is no dipterous insect peculiar to man alone, but a number 
of cases are on record where the ova of several species of oestrus 
have been deposited in the skin, and larvse been subsequently formed. 
The oestrus bovis, or gad-fly, is the most common of these. Usually, 
after the ova are deposited by the insect, a painful swelling occurs 
which may change from one point to another. When suppuration is 
induced, the larvse can be removed by pressure upon the boil. 
Walter Smith, 1 of Dublin, has described such a case, where the 
swelling upon the ankle of a girl twelve years old, moved to the 
elbow, and there discharged a white grub nearly an inch in length. 
Birdsall 2 has described a specimen sent him from Gaboon, on the 
West Coast of Africa, in which two worms escaped from between the 
middle and the ring fingers of one hand ; another workman having 
had a similar accident occur upon the leg. The fly whose ova had 
been deposited in these two cases, was said to attack the gorilla ; and 
members of a native tribe engaged in capturing these animals 
were reported as being very commonly troubled in the same way. 
The worms sent to Dr. Birdsall were respectively one-fourth and 
one-half of an inch in length, and about one-eighth of an inch in 
thickness. 

Abraham, of Dublin, has also examined and reported upon a 
similar case, the specimen having been sent to the editor of the 
London Medical Press and Circular, from Portsalon, Letterkenny. 

Several specimens illustrating these accidents have been sent to the 
author from neighboring States. The larvse represented in the sub- 
joined sketch were removed from the body of an infant in Nebraska. 
The muscidse (flesh, house, stable, dung, and other flies) have defec- 
tive maxillae, and are, therefore, unable to wound the uninjured skin. 
The pregnant female seeks, therefore, to deposit her ova where the 
larvse, equally unprovided with developed jaws, can most readily 
secure nutriment. Hence, open wounds and the tender skins of 
newly born infants when exposed in the summer season, are liable 
to become the depots of such ova. 

1 See Report of Internat. Med. Congress, Arch of Derm., January, 1882. 

2 N. Y. Med. Record, March 18, 1882, p. 298. 



ANIMAL PARASITES. 



773 



The ova of other species of niuscidse and cestridse (according to 
Geber, of the former, Lucilia Csesar, in America ; Stominis Calcitrans, 
in Africa ; and Sarcophila Wohlfati, in Russia ; of the latter, 
Dermatobia Noxalis, Cartrebra, and Hypoderma) deposit ova or larvae 
in the skin by their special apparatus for puncture, occasionally also 



Fig. 103. 

<C3HE> 



Fig. 104. 




a 



CEstrus. a, the larva, natural size ; 6, 
some of the segments seen under a lens, and 
showing the lines of minute projection ; c 
and d, the terminal ends of the insect. 
(After Abraham.) 



Larvae removed from the body of a child. 
Of the exact size, after several days in alco- 
hol ; a, as seen from side ; b, as seen from 
beneath. 



the hatched larva works its way unaided from the epidermis to the 
subcutaneous tissue. Severe cases are reported from Texas, where 
larvae have been expelled in great number from the nares after 
inhalation of chloroform. 



Ixodes (Wood-tick). 

Several species of ticks are recognized, such as the Ixodes 
Humanus, Ixodes Bovis (cattle-tick), Ixodes Americaxus, 
Ixodes Margixatus, Ixodes Uxipuxctatus, and the Ixodes 
Bjcixus (wood-beetle), the last named being more common in 
Europe. In this country they are found in wooded districts, espe- 
cially those where pine and fir trees are growing. The female attacks 
the skin by thrusting into it her beak, armed on either side with a 
maxillo-labial projection having recurved hooklets, the mandibles also 
presenting similar obstacles to the forcible extraction of the head. 
After suction of the blood from beneath, the body of the tick swells 
to the size of a pea or small bean, and may remain for several days 
in this position. At such times the parasite may be mistaken for a 
small pedunculated tumor. Forcible attempts at extraction of the 
intruder are liable to detach the mandibles from the body, and thus 
leave them as the source of future irritation, and even disagreeable 
inflammatory symptoms, in the site of the punctured wound. By 
applying over it a drop of the spirit of turpentine or benzine, the 
head is spontaneously retracted, and the body falls from its position. 
The soldiers on the plains of our own country, accomplish the same 
end with the juice of tobacco. The sensation produced at the moment 
of the insertion of the beak of the insect is said to be so trifling as 
often to pass unnoticed. 



774 DISEASES OF THE SKIN. 

Pediculosis. 

Lat., pediculus, a little foot. 

(Phtheiriasis ; Morbus Pediculosis ; Lousiness.) 

Pediculosis is a contagious affection, characterized by the presence of lice upon 
the skin and hairs, by the wounds inflicted by the parasites, and by the scratch- 
ing which the resulting pruritus excites. 

Symptoms. — Lice belong to the order rhynchotta ; subdivision 
parasitce ; family, pediculidce. They are apterous, provided each with 
two eyes, and have an oral appendage capable of both inflicting 
wounds and producing suction. The lice infesting the human body 
are recognized as belonging to three varieties, those of the head, of 
the body, and of the pubes. Of the disorders to which they give rise 
it may be said in general, that the lesions presented differ somewhat 
according to the region invaded, the multiplicity of the intruders, 
and the length of time during which their ravages have been inflicted. 
Such lesions, however, are those which have been already studied in 
connection with eczema, urticaria, and the similar disorders resulting 
from external irritation. Their special peculiarities in pediculosis, 
are owing solely to the nature of the exciting cause and the mode of 
its operation. 

Pediculosis Capillitii (Parasite, the Head Louse). 

Statistical frequency in America, 2.09. 

The head louse is usually of a grayish color, but differs slightly 
with the hue of the hairs over the part which it frequents. Its head 
presents indistinctly the outline of a trefoil, and 
is provided with two hairy antennae, each of five 
articulations, and two eyes. Its thorax is rela- 
tively narrow, with six tracheal stigmata and 
three hairy legs on either side, the latter pro- 
vided with tarsal hooklets. The abdomen is 
divided into seven segments, defined by blackish 
indentations on either side. The males are 
fewer and smaller than the females, and pre- 
sent upon the dorsum an ano-genital orifice and 
a large conoidal penis and testes. The females are 
provided with ovaries, oviducts which termi- 

Pediculus capillitii— male. r . . , . , , n -, 

(After kuchenmeister.) nate in a vagina having a ventral orifice and 
an anal aperture in the terminal abdominal seg- 
ment. Coupling is performed with the male beneath. 

The ova or " nits " are whitish bodies of oval contour, which are 
glued to the hairs by a cylindriform sheath of chitin, which com- 
pletely encases the circumference of each filament. They are deposited 
in series, as the female traverses the hair from its insertion to its 
distal extremity, so that the oldest are in general the nearest to the 




PEDICULOSIS, 



775 



Fig. 106. 



scalp. The young escape from the ova in from three to eight days, 
and arrive at maturity in from eighteen to twenty days. A single 
female can, according to Kaposi, lay fifty eggs in six days, and thus 
in eight weeks have an entire progeny of five thousand lice. 

Head lice usually limit their habitat to the scalp, though, rarely, 
in elderly men with long hair reaching to a full beard, they may 
encroach upon the latter. They infest every portion of the scalp, 
but find the region of the greatest protection upon the occiput. They 
are found upon children and adults of both sexes, but are best fur- 
nished with lodgment in the scalps of girls and women covered by 
long and luxuriant hair. 

The lesions observed upon a scalp thus inhabited, vary according 
to the age and vigor of the colony ; and are few or numerous, discrete 
or confluent pustules or bullae ; surfaces ex- 
coriated by scratching and oozing with serum, 
pus, or blood ; crusts varying in character 
according to the nature of the desiccated ex- 
udate and sebaceous matters. Often the 
picture presented is a conglomerate of an 
artificial eczema and seborrhoea. 

The ova, or " nits," are usually abundaut 
upon the hairs of an infested head, and will 
scarcely escape the attention of a close ob- 
server. They are not to be mistaken for the 
exfoliated, epithelial, and fatty plates seen in 
seborrhcea sicca, disseminated among the 
hairs, and often perforated by hairy fila- 
ments, since the former are firmly glued in 
position, and resist the bristles of the hair- 
brush. The peculiarly nauseating odor also 
of the louse-infested, pustule- and crust- 
covered scalp is not to be confounded with 
that perceived in favus of the same region. 

In exaggerated cases, the post-cervical gan- 
glia express, by their increase in size, the 
degree to which the local irritation has been 
pushed. The itching is usually severe, and, 
in cases of long persistence in children, may 
produce the usual systemic symptoms of pro- 
longed local irritation. Children and patients 
of impoverished health and with poor hygi- 
enic surroundings, are thought to exhibit the 
disease in severer grades than others ; but 
this, if indeed a fact, must be at least in 
part due rather to the more favorable condi- 
tions for the development and multiplication 
of the parasites, which are presented in filth accumulation and lack 
of cleanliness. In the public charities of large cities, children are 
presented every week affected with pediculosis capillitii, who come 




¥ 




Ova of the head-louse attached 
to hair. 1, 2, 3, ova ; a a, chi- 
tinous cylinder surrounding 
a pilary filament ; b, chiti- 
nous sheath of ovum nearly 
mature. (After Kaposi.) 



776 DISEASES OF THE SKIN. 

from the very lowest social grades of population and from the 
filthiest quarters. Among these it cannot be observed that the gen- 
eral health of the patients is a factor of weight in the severity of the 
affection. 

The Diagnosis of pediculosis capillitii is a matter of considerable 
importance, however simple of accomplishment, since many cases of 
supposed " pustular eczema of the scalp " have been treated vainly 
by one physician with internal remedies addressed to the systemic 
vice assumed to be responsible for the disease which another has re- 
lieved after the discovery of a few head-lice. The hairs should always 
be raised and separated, the scalp carefully inspected, and the pres- 
ence of any parasites, and especially ova or " nits " fastened to the 
hairs, ascertained. Whether the lice have preceded or followed the 
eczematous state (and each of these conditions may be noted) is a 
matter of minor importance. 

The indications in the Treatment of pediculosis capillitii are the 
destruction of all parasites with their ova, and the relief of the 
induced inflammatory condition of the scalp. Generally, the removal 
of the former is followed by the spontaneous disappearance of the 
latter. 

For the destruction of the lice, the most popular remedy, in this 
country certainly, is petroleum [not kerosene], pure or with equal 
parts of the balsam of Peru, which gives it a more agreeable per- 
fume, poured over the scalp in quantity sufficient to cover it without 
overflow upon the brow, temples, and neck. It should be rubbed in 
with a piece of white (undyed) flannel. At the end of from twelve 
to twenty-four hours the lice are destroyed, and the ova rendered in- 
capable of development. This treatment is followed by a thorough 
shampoo with tincture of soap, or toilet soap and hot water ; after 
this operation the tender scalp may require a bland unguent, such as 
vaseline, or a small quantity of scented castor oil, either pure or in 
combination with spirits of wine. Kaposi employs petroleum as a 
parasiticide in combination with olive oil and balsam of Peru : five 
parts of the first, two and a half of the second, and one of the third. 
Cutting the hair of women and girls is quite unnecessary, as patience 
and gentleness with the use of the comb will finally disentangle the 
most matted masses after the lice have been destroyed. Other reme- 
dies are employed locally for a similar purpose, of which the most 
popular are staphysagria, one drachm (4.) of the powdered seeds to 
the ounce (32.) of vaseline, but especially in decoction ; the tincture 
of cocculus Indicus ; carbolic acid in oil or water ; sabadilla ; the 
ethereal oils ; and mercurials in ointment and solution, including the 
mercuric oleates. In cases where but a few parasites have found 
their way to the scalp, and that recently, nothing more is requisite 
than a careful use of the fine-toothed comb, scrubbing the scalp with a 
strongly scented alcoholic perfume, and a final bathing with soap 
and hot water. 

The ova adhering firmly to the hairs can be removed by soda or 
borax lotions, alcoholic solutions, or dilute acetic acid, which are 



PEDICULOSIS. 



solvents for the gluey material by which the " nits " are secured in 
place. 

Pediculosis Corporis (Parasite, the Body Louse ; Pediculus 
Vestimenti). 

Statistical frequency in America, 1.38. 



disorder inhabits exclusively the 



clothing 



Fig 




■ET 



9 



The parasite iu this 
worn next the body. In anatomical peculiarities it resembles the 
pediculus capillitii already described, being, however, larger in size, 
the females also larger than the males. The thorax is separated from 
the abdomen, the latter being hairy, yellowish at the margins, and 
provided with eight segments. The eyes are black, and very promi- 
nent in both sexes ; and the periods requisite for the maturing of 
the ova and youug are those named respectively in connection with 
head lice. In color they vary slightly from a dirty white to a light 
grayish hue when undistended with blood. In 
the reverse of this last-named condition, they may 
be recognized as having a dull reddish or purplish 
color, when they are also more iudolent in their 
movements. They measure 2 to 3 mm. in length, 
and 1 to 1.5 mm. in breadth. The female lays 
from seventy to eighty eggs, from which the 
youug are produced in from three to eight days, 
and are capable of reproduction in a fortnight 
more. 

They inhabit the seams of undergarments, 
where their ova are also deposited, but in coarse 
woollen or flaunel shirts they find sufficient shelter 
in the meshes of the material of which the cloth- 
ing is made. This they leave temporarily, solely 
for the purpose of obtaining nutriment from the 
skin of their host, and hence are not often recog- 
nized upon the free surface of the integument. 
Upon rapid removal of the clothing of an infested individual, a few 
may occasionally be encountered, hastily seeking a place of refuge, 
though this is rather the exception to the rule. It thus may happen 
that a louse-bitten patient may not exhibit the true source of his 
troubles to his physician after a recent and complete change of cloth- 
ing. The greater then the importance of being able to recognize the 
clinical features of the malady in the absence of the parasite. This 
is comparatively easy to one who has made himself familiar with the 
symptoms of the disorder. 

The manner in which the louse is enabled to supply itself with the 
blood of man has been carefully studied by Swammerdam, Landois, 
Schjodte, and Tilbury Fox. The last-named author has summarized 
the observations of the others, and the results he gives may be brieflv 
descibed as follows : 

Swammerdam's original view that the louse is not provided with 



Pediculus corporis — 
female. (After 

KuCHENMEISTEE.) 



778 DISEASES OF THE SKIN. 

mandibles by which it can inflict a wound, but with an haustellum 
by which the blood is sucked up to the head of the parasite, is con- 
firmed by Schjodte. This observer, examining the head of the louse 
from behind with reflected light, discovered that the parts of the 
head resembling mandibles in appearance, were really situated be- 
neath its skin. He applied to the integument lice which had been 
previously starved, and watched each as with retracted limbs, arched 
back, and head inclined obliquely downward, it repeatedly projected 
forward and retracted through the extreme end of its head a " small, 
dark, narrow organ," by which it was finally firmly held iu place. 
A triangular blood-red point soon became visible in front of the eyes, 
rapidly and alternately contracting and dilating, and followed by 
energetic peristalsis of the gastro-intestinal tract. If the head then 
be cut off in front of the eyes, and the haustellum carefully extracted, 
the latter can be recognized as a brownish protrusion, armed with 
terminal recurved hooks, from which depends a delicate membranous 
tube varying in length. 

" It seems that the mouth is like that in the rhynchotta generally, 
but differs in the circumstauce that the labium is capable of being 
retracted into the upper part of the head, and has a fold in it when 
so retracted. In order to strengthen this part, a flat band of chitin 
is placed on the under surface ; and it is thinner in the middle in 
order that it may bend and fold a little when the skin is not extended 
by the lower lip. The latter consists of two hard lateral pieces, of 
which the fore ends are united by a membrane, so that they form a 
tube, of which the internal covering is a continuation of the elastic 
membrane on the top of the head. Inside its orifice are a number of 
small hooks, which assume different positions according to the degree 
of the protrusion ; and if this be pushed to its highest point, they 
form a collar of hooks curved backward like barbs. The pediculus 
first inserts its labium into a sweat-pore and protrudes the lip. When 
the hooks get hold of the parts around, then the first pair of seta? 
(the real mandibles transformed) are protruded, and these are toward 
the point invested by membrane so as to form a closed tube, from 
which again is exserted a second pair of setae or maxillae, which form 
a tube and end in four small lobes placed crosswise. The whole 
forms a membranous tube, along the walls of which retiform man- 
dibles and maxillae are placed as long narrow bands of chitin. This 
tube can be lengthened or shortened at pleasure." 

This explanation of the mode in which the louse attacks the skin 
is probably true of each of the varieties which infest the human 
body. Fox well suggests that the invaded follicle, after the with- 
drawal of the haustellum, becomes the seat of a circumscribed haemor- 
rhage. None of the anatomical peculiarities described above will, 
however, completely explain, it seems to the author, the characteristic 
pruritus of pediculosis corporis, for it can scarcely be questioned that 
it is not merely at the moment of attack or penetration that the 
suffering of the victim is greatest. The pruritic condition of the 
louse-wound persists, indeed usually attains its maximum, after the 



PEDICULOSIS. 779 

withdrawal of the pediculus, and is without doubt greater than that 
awakened by merely mechanical puncture of the epidermis. Any 
one who will compare the skin of a louse-infested patient with one 
who has been subjected to the acupuncture process employed among 
the lower classes of Germans, and by them known as " baunscheidt- 
ismus," can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate irregularly from. each louse-wound, and 
may be commingled with minute papules, transitory wheals, or, in 
rare, exaggerated cases, with the typical signs of diffuse eczema. All- 
are produced by scratching in order to relieve the pruritus. Crusts, 
more often composed of desiccated blood, rarely of serum or pus, 
minute and capping the wounded follicle, or linear and coextensive 
with the excoriations produced by the scratching, are generally con- 
spicuous. In older cases these lesions are followed by the usual 
sequel, pigmentation, the latter being a partial indication of lousiness 
which has been long tolerated. 

In this country, it is rare to note the severe and intense forms of 
the malady resulting from long- continued neglect of the skin, which 
occur in Germany. In such cases, dermatitis, rupioid crusts, fur- 
uncles, abscesses, carbuncles, and ulcers form, bequeathing to the 
skin serious disorders, which may persist for weeks after the clothing 
has been freed from lice, and finally leaving a deep-tinted, diffuse 
pigmentation of the surface, suggesting that of the negro or of the 
patient affected with Addison's disease. 

The Diagnosis is a matter of importance. Patients will visit 
physicians, claiming that they have suffered from a " humor of the 
blood," who have been swallowing drugs for a long period of time, 
in the vain hope of obtaining relief, with lice, at the very moment of 
uttering the complaint, crawling over their persons. Even those of 
good social position and habits of cleanliness, will occasionally suffer 
after the accidental contacts in the street- or railway-carriage, the 
hotel, the theatre, or other places of public resort. There are certain 
points to be carefully noted in this connection. Excoriations over the 
nucha, about the shoulders, loins, buttocks, and external faces of the 
thighs, all visible at the same time, are highly suspicious symptoms; 
as an eczema, when equally diffuse, is sure to be accompanied at some 
point by perfectly classical features ; and generalized pruritus is 
exceedingly rare, its localized varieties concerning chiefly the regions 
about the mucous outlets of the body. There is a picture highly 
suggestive of pediculosis exposed to the eye when the trunk of an 
infested patient is viewed from behind. The lesions are more discrete, 
more irregularly distributed, and more intermingled with long scratch - 
marks, reaching, for example, quite over the point of one shoulder, 
than in most disorders with which this could be confounded. Here 
and there minute blood-specks tell a significant tale. The author has 
occasionally the opportunity to exhibit patients at the clinic, with 



780 DISEASES OF THE SKIN. 

syphilodermata interspersed among characteristic lesions of pedicu- 
losis corporis ; and often the students themselves in such cases point 
out the particular symptoms referable to the separate disorders 
present. 

In private practice it is usually advisable, for obvious reasons, to 
secure the corpus delicti before informing the sufferer of the nature 
of his or her complaint. In the case of male patients, it is well to 
take a position in the rear, and when the underclothing is drawn 
well up from the shoulders, a careful scrutiny of it may be made 
while the applicant for relief supposes that attention is directed 
instead to his person. 

The Treatment of the disorder concerns largely the clothing. The 
latter requires immersion in boiling water, or may be wrapped in 
paper and subjected to a high temperature in an oven, 160°-175° F., 
sufficient to destroy the lice and their ova. In case of recurrence of 
the malady, the clothing is to be again subjected to the same process. 
Usually the resulting irritation of the skin promptly subsides. 
When several members of one family suffer, all clothing worn must 
be subjected to similar treatment. If the skin has been unusually 
tormented by scratching, warm alkaline baths will afford some com- 
fort, and may be followed by a bland unguent or one of the dusting 
powders. For immediate use, before the clothing can be rid of the 
intruders, a parasiticide ointment can be ordered as recommended by 
Duhring, prepared by adding two drachms (8.) of freshly powdered 
staphysagria to the ounce (32.) of hot lard, strained and cooled. The 
surface of the skin may also be anointed with carbolic acid dissolved 
in oil or water. 

Pediculosis Pubis (Parasite, the Pubic Louse, Crab Louse. 

Fr., Morpion.) 

Statistical frequency in America, 3.52. 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 
including the eyebrows, eyelashes, axillae, and the mustache, beard, 
hairy chest, and hairy legs of the male. The body of the pubic 
louse is smaller than either of those described above. Its head is 
also attached more closely to its thorax, having a shape which is 
compared to that of a violin. The thorax is not distinctly separated 
from the abdomen, and of the six stout legs that spring from it, the 
second and third pair are conspicuously powerful, and armed with 
relatively large hooks at the tarsal extremity. The resemblance of 
the latter to the claws of a crab, has given to this creature the 
common name of " crab louse." The lateral abdominal indentations are 
much less distinct than in the other varieties ; and the blackish 
marginal marks of the latter are here scarcely apparent. The abdo- 
men is also much elongated, having a more rounded contour, and 
being provided on its lateral borders with eight short conical feet, 
terminating in bristles. It is also distinguished from the others of 



PEDICULOSIS. 781 

its family by the leugth of its anal bristles, and by the peculiar shield- 
shaped carapace which covers nearly one-half of the dorsum. The 
male is 0.8 to 1. mm. long, and 0.5 to 0.7 mm. in width, being 
thus from 1. to 1.5 mm. smaller than the female. 

The pubic louse is much more inactive than the others, and does 
not ordinarily escape its pursuer. It buries its head deeply in a fol- 
licular orifice, and steadies itself in this position, where it may remain 
for some time, by grasping the adjacent hairs with its short and 
powerful claws. A moderate degree of force is required for its 
dislodgment from this favorite position, and when removed its grasp 
of the hair to which it clings is so firm that the latter usually slides 
for its entire length through the claw of the louse. Occasionally 
they may be found creeping over the skin or clinging to hairs at a 
distance from the surface. The pyriform ova are smaller than those 
of the head louse, though having a similar color , and are, like the 
latter, attached to the hairs by a firm chitinous glue. 

Pubic lice are usually acquired during the contacts incidental to 
the sexual act ; and are hence more frequently encountered among 
adults, but may, without any question, 
be more rarely transmitted mediately fig. ios. 

by occupation of beds and covering 
which have been used by infested per- 
sons. They are thus, though very 
rarely, found in children of both sexes. 

The lesions induced are those pro- 
duced by the wounds inflicted by the 
parasites and by constant scratching, 
though the latter is rarely intense. In 
a few cases, one may see a severe eczema 
follow the ravages of the lice, but in 
such event the complication is chiefly 
owing to unnecessarily severe self- 
treatment of the disorder, patients 
being often morbidly anxious in their Pedicuius pubis. (After schmarda.) 
efforts to rid themselves of the pests. 

The Diagnosis of pediculosis pubis is between eczema and pruritus 
genitalium. The disease last named is, in both sexes, accompanied 
by itching, and that often of intense grade, but when this is diffuse 
and symmetrical in distribution, it is not limited particularly to the 
hairy parts. Eczema of the genitals is not often produced by para- 
sites of that region, and may be readily recognized by its character- 
istic features. Both disorders are often indeed limited to symmetrical 
patches upon the side of the scrotum or one labium. The discovery 
of the parasite, however, in pediculosis pubis, is always essential, and 
requires merely careful inspection and a good light. The lice may 
be recognized either at or near the point of implantation of the hairs, 
which latter also display ova except in very recently infested indi- 
viduals. The reddish excrement of the parasites mingled with 
scratch-marks and excoriated papules of small size, may also be 




782 DISEASES OF THE SKIN". 

observed. Patients are often made aware of their condition by a 
sensation of crawling over the parts. Scratching of the pubic 
region in adults of both sexes should awaken some suspicion of the 
disorder. 

The disease is commonly treated by the topical application of 
mercurial ointment, which is a disagreeable and rather filthy medica- 
tion for this locality. The ten per cent, oleate may be substituted 
for it, or, even preferably, corrosive sublimate in solution, three to 
four grains (0.2-0.266) to the ounce (32.). Petroleum and olive oil 
with the balsam of Peru, in the proportions given above in connection 
with the subject of pediculosis capillitii, is an effective combination. 
Staphysagria, carbolic acid, cocculus indicus, or one of the other 
substances used in the disorders occasioned by the animal parasites, 
may be substituted if desired. ■ 

It is usually better to defer bathing till the remedy selected for 
the destruction of the lice has been applied on several occasions, after 
which a warm water and soap ablution will commonly end the 
trouble. It is needless to clip the pubic hairs. Should an eczema- 
tous disorder remain, it requires appropriate treatment, including hot 
bathing and the blander lotions and unguents. 

Vagabond's Disease. — This is a term given to the condition of 
the skin recognized among tramps, inmates of poorhouses, and the 
filthy and neglected in general. The skin of such persons is often 
densely indurated, harsh, dry, and deeply pigmented, in consequence 
of much scratching and a consequent hyperseniia. It is produced 
chiefly by phtheiriasis ; but is often a resultant of the incursions of 
several parasites including those of the bed and of the clothing. It 
is also a consequence of persistent neglect of the bath. 

PEDICULI AND ACARI TRANSFERRED TO MAN FROM THE LOWER 

Animals rarely thrive in such uncongenial soil, but as a matter of 
exception, occasionally survive such transfer. Thus Goldsmith, 1 of 
Vermont, reports the case of a woman affected with intense pruritus, 
who after sweating profusely observed numbers of pigeon- or hen- 
lice emerging from the sweat-pores. Megnin 2 reports similar cases 
under the title Prurigo Dermanyssique, the dermanyssus avium, 
or gallinse, being the acarus infesting domesticated fowls. The dis- 
order is said to be at times epidemic in the vicinity of aviaries and 
pigeon-cotes, but is always of trifling severity. 

Cimex Lectularius (Acanthia Lectularia, Bugs, or Bedbugs). 

Strictly speaking, the bug is not a parasite of man, but finds its 
congenial habitat in the bed, bedding, bed-covering, and walls and 
floors of apartments occupied by persons of both sexes and all ages. 

1 Louisville Med. News, Dec. 31, 1881, p. 320. 

2 Les parasites et les maladies parasitaires chez l'homme, les animaux domestiques, etc., 
Paris, 1880. 



INSECTS ATTACKING THE SKIN. 783 

It infests also furniture, including chairs, sofas, and the cushions of 
seats occupied in public vehicles aud hotels. From the cracks, 
crevices, seams, folds, or other protected points where it has found 
lodgment, it emerges usually at night, for the purpose of securing its 
nutriment in the blood of its victims. It is a pest as ancient as the 
day in which Dioscorides wrote. 

The insect has a rusty or reddish color, this differing slightly 
according as it is or is not distended with blood. It is an apterous 
member of the order Cimicid^: ; and is provided with a blunt- 
pointed head, broadly attached to the thorax ; two long slender 
antenna? ; and a three-jointed haustellum capable of projection and 
retraction beneath the head. There are three pairs of long slender 
legs by which it is enabled to accomplish rapid movements, two 
thoracic and four abdominal. The abdomen is broad, flattened, and 
oval in shape, with nine segments. The parasite emits a disgusting 
odor, which is much more distinct when it is crushed. 

The wound inflicted by the bug is accomplished with or without 
the consciousness of its victim, who in the former case is made aware 
of a transitory prick or sting. Soon after, decidedly pruritic burning 
or stinging sensations are experienced ; and the wound becomes the 
seat of an urticarial wheal. The lesion then, examined soon after 
the infliction of the wound, is seen to be small pea- to bean-sized, and 
in the form of an elevated and circumscribed " button " or papulo- 
tubercle, either whitish in the centre, or exhibiting there also the 
hyperemia which distinguishes its peripheral zone. After it has 
begun to subside and lose its acute features, which may not occur for 
several hours if it be irritated by rubbing or scratching, a minute 
reddish puncture may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 
has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this 
way at times its course upon the integument may be for a short 
distance traced. In cases where the pests are numerous, as in filthy 
dwellings, prisons, ships, and barracks, and when infants have been 
attacked, the resulting eruption is often greatly masked by the 
scratching and resulting excoriations of the surface. In this way 
vesicles, pustules, crusts, purpuric blotches, and even skin infiltra- 
tions may be found, instead of the rosy or light reddish typical 
wheals of recent cases in patients with fair clean skins. The diag- 
nosis is a matter of importance, and upon it may hang a professional 
reputation. Physicians are often consulted respecting these lesions 
by patients who believe themselves to be suffering from " humors/' 
exanthemata, and even syphilis. The insect attacks the parts of the 
body to which access is easy as the patient sits or reclines on the back 
or side, including the buttocks, thighs, shoulders, loins, and neck, in 
that order of frequency, rather more largely than the legs, much less 
frequently the scalp, face, and genitalia. The eruption is not to be 
confounded with urticaria ab ingesiis, which is more apt to be sym- 
metrical in disposition. 



784 DISEASES OF THE SKIN. 

It is best relieved by the topical application of spirits of camphor, 
alcohol, weak carbolated lotions, or solutions of boric acid, one 
drachm to the pint. Untreated, it disappears spontaneously when 
the source of the disorder is removed. The most effective treatment 
is by prophylaxis, with soap, corrosive sublimate, and hot water, 
of all accessories of the dwelling-house inhabited by the insects. 
Once discovered to be present, infested furniture should be scrubbed 
in all its crevices with a saturated solution of corrosive sublimate in 
alcohol, and bed-clothing immersed in boiling water. 

Other insects, which may persistently or only occasionally 
attack the human skin, are : the mosquito and gnat (Culex Pipiens); 
midges (Tipulidje, Simulia) ; bees (Apes Mellifef^e) ; and 
wasps (Yespid^:). 

Culex Pipiens, etc. 

Mosquitoes, midges, etc., produce, by their bites or stings, various 
cutaneous lesions, including urticarial wheals, papules, ecchymoses, 
and in rare cases even eechymomata. Those produced by the flea 
are found more often on the legs, neck, or other covered portions of 
the body ; those of the midge and mosquito on the face, hands, and 
exposed parts ; though, when numerous and voracious, these insects 
will penetrate the clothing for the purpose of obtaining blood. 
Severe eruptive lesions are often seen in this country on the faces and 
extremities of infants and children exposed during the night to the 
incursions of these marauders. They are usually treated locally by 
aqua ammoniac or the spirits of camphor. 

The bodies of immigrants newly arrived during the summer season 
in America, from countries where the mosquito is either rare or does 
not exist, often present singular and even formidable evidences of the 
attacks of these insects. The skin, totally unaccustomed to such 
depredations, and quite unprotected, will often be found greatly 
swollen, and of a light reddish hue suggestive of erysipelas. Here 
and there bullae are conspicuous, which add to the resemblance to the 
last-named disease. The features, in consequence of the tumefaction, 
vesiculation, and papulation, may be so swollen as to present a con- 
spicuous deformity ; and the forearms, and even the arms, seem 
greatly increased in size from the same cause. The feet and legs also 
may be, in the unconsciousness of sleep, exposed in hot weather to 
the depredations of these marauders, and in the same way the back, 
buttocks, and, rarely, even the genitalia present the same signs of 
inflammation. The matter of chief moment is the correct diagnosis 
of such cases, as many patients seeking relief under such circum- 
stances have been treated for disorders with which they were not 
affected. 






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50 



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INDEX 



ACANTHIA lectularia, 782 
Acanthosis nigricans, 447 
Acari transferred to man from lower ani- 
mals, 782 
Acarus folliculorum, 128, 765 
hordei, 772 
scabiei, 756 
Achroma, 487 
Achromia unguium, 516 
Acne, 372 

diagnosis, 377 
etiology, 376 
pathology, 377 
prognosis, 384 
symptoms, 372 
treatment, 378 
albida, 132 
artificialis, 373 
atrophica, 373, 389 
cachecticorum, 373 
Acne cancroidale, 541 
Acne, contagious, 375 

cornea, 375 
Acne decalvante, 510 
Acne disseminata, 375 
frontalis, 389 
hypertrophica, 373 
hid u rata, 373 
keratosa, 375 
necrotica, 389 
papulosa, 374 
parasitica, 375 
Acne ponctuee, 126 
Acne punctata, 374 
rodens, 389 
rosacea, 384 

diagnosis, 386 
etiology, 385 
pathology, 386 
prognosis, 389 
symptoms, 384 
treatment, 387 
Acne 1-osee, 384 
Acne sebacea, 113 
Acne sebacee, 113 
Acne sebacee cor?iee, 421 
Acne tuberculoses, 566 
varioliforme, 389 
Acne varioliforme (of Bazin), 426 
Acne varioliformis, 389 
diagnosis, 390 
etiology, 390 



Acne varioliformis, pathology, 390 
symptoms, 389 
treatment, 390 
vulgaris, 374 
Acrochordon, 529 
Acrodynia, 664 
Acromegaly, 478 
Actinomycoses 745 
Actinomycosis, 745 
diagnosis, 746 
etiology, 745 
pathology, 745 
prognosis, 746 
symptoms, 745 
treatment, 746 
Acute circumscribed oedema, 177 
of the skin, 465 
diagnosis, 466 
symptoms, 465 
treatment, 466 
idiopathic oedema, 177 
non-inflammatory oedema, 177 
purulent oedema, 225 
Addison's disease, 414 

keloid, 469 
Adenoma, 541 

of the coil-glands, 541 
of the sebaceous glands, 511 
Adenomes sebaces, 541 

cancroidaux, 541 
Aden ulcer, 224 
Ainhum, 590 
Aktinomykose, 745 
Albinismus, 488 
symptoms, 488 
etiology, 489 
Albinoes, 488 
Albugo, 516 
Aleppo evil, 223 
Alibert's keloid, 522 
Alopecia, 494 

pathology, 497 
symptoms, 494-497 
treatment, 497 
areata, 501 

diagnosis, 505 
etiology, 503 
pathology, 505 
prognosis, 507 
symptoms, 501 
treatment, 506 
congenital, 495 



788 



INDEX. 



Alopecia circumscripta, 501 
false, 509 
follicularis, 508 
furfuracea, 499 
diagnosis, 500 
etiology, 500 
pathology, 500 
treatment, 500 
neurotica, 508 
pityrodes capillitii, 499 
premature, 496 
pre-senile, 496 
senile, 496 
Alopecias, cicatricial, 509 
Alphos, 257 
Anaesthesia, 706 
Analgesic paralysis of the upper limbs, 

475 
Anatomical tubercle, 564 
Anatomy of the skin, 17 
Anderson's dusting powder, 168 
Angiokeratoma, 425 
Angioma, 544 

etiology, 548 
pathology, 548 
prognosis, 550 
treatment, 550 
cavernosum, 547 
infective, 550 

pigmentosum et atrophicum, 553 
diagnosis, 555 
etiology, 555 
pathology, 554 
prognosis, 555 
symptoms, 553 
treatment, 555 
serpiginosum, 550 
Angioneurotic oedema, 177, 465 
Anidrosis, 107 

treatment, 108 
Anthemata, 61 • 
Anthrax, 215 
maligna, 218 

diagnosis, 219 
etiology, 219 
pathology, 219 
prognosis, 220 
symptoms, 218 
treatment, 220 
simplex, 215 

diagnosis, 217 
etiology, 216 
pathology, 216 
prognosis, 218 
symptoms, 215 
treatment, 217 
Apes melliferae, 784 
Aplasie moniliforme inter?nittente, 513 
Araroba em po, 273 
Area Celsi, 501 

Johnstoni, 501 
Argyria, 414 
Arrectores pilorum, 35 
Arsenic in cutaneous diseases, 78 



Arteries of the skin, 28 
Asteatosis, 136 

prognosis, 137 

symptoms, 136 

treatment, 136 
Atheroma, 134 
Athrepsie, 464 
Atrophia cutis, 517 

maculosa et striata, 518 

pilorum propria, 511 

senilis, 517 
Atrophies, 487 

of pigment, 487 
Atrophy, diffuse idiopathic, 520 

of hair, 494 

of nail, 516 

of skin, blanching, 520 

partial, idiopathic, 518 
partial symptomatic, 519 
Aussaiz, 649 



BACILLOGENOUS dermatoses, 211 
sycosis, 226 
Baldness, 494 

" Bald tinea tonsurans," 729 
Barbadoes leg, 475 
Barber's itch, 735 
Bartfinne, 226 
Baths, 83 
Beaded hairs, 513 
Bedbugs, 782 
Bees, 784 _ 
Beigel's disease, 515 
Bellamy's iodized phenol, 338 
Benign cystic epithelioma, 683 
Benzoated lard, 334 

sebum, 334 
Biskra bouton, 223 
Black-head, 126 
Black measles, 152 
BLasenaiisschlaq, 392 
Blebs, 57 

Bleeding stigmata, 708 
Bloodvessels of the skin, 28 
Bloody sweat, 112 
Body louse, 777 
Boil, oriental, 223 
Boils, 211 

Bowditch Island ringworm, 743 
Brandy-drinker's nose, 483 
Bromhidrosis, 108 
Bromidrosis, 108 

etiology, 109 

pathology, 109 

treatment, 109 
Brother ulcer, 486 
Buccal psoriasis, 683 
Bucnemia tropica, 475 
Bugs, 782 
Bulb of hair, 39 

Bulkey's liquor picis alkalinus, 335 
Bullae, 57 

haemorrhagicae, 404 






INDEX. 



789 



Burmese ringworm, 742 
Burns, 189 



pACHEXIE pachvdermique, 709 
\J Callositas, 432 

of the hands with complications, 
433 
Calorimeter, 95 
Calotte, 718 
Calvities, 494 
Cancer, 665 

en cuirasse, 680 

epithelial, 665 

fibrous, 680 

hard, 680 

lenticular, 680 

of connective tissue, 680 

of extremities, 671 

of genital organs, 670 

of head, 670 

of lower lip, 670 

of mucous surfaces, 671 

scirrhous, 680 

spider, 546 
Cancroid, 522 

ulcer, 666 
Cancro'ide, 665' 
Canities, 492 

etiology, 493 

pathology, 493 

symptoms, 492 

treatment, 494 
Canker rash, 143 
Carbuncle, 215 
Carbunculus, 215 
Carcinoma, 665 

diagnosis, 676 
etiology, 673 
pathology, 674 
prognosis, 680 
treatment, 677 

epithelial, 665 

melanotic, 682 

pigmented, 682 

tuberosa, 682 
Cascadoe, 742 
Caustics, 92 

Cellulome epithelial eruptif, 683 
Cement substance, 23 
Chalazodermia, 531 
Chancre, 593 

non-infecting, 644 

simple, 644 

soft, 644 
Chancroid, 644 
Charbon, 218 

Cheiro-pompholyx, 112, 255 
Cheloid, 522 
Chignon fungus, 515 
Chigoe, 765 
Chicken-pox, 155 
Chilblains, 164, 190 
Chloasma, 412 



Chloasma, diagnosis, 415 
pathology, 415 
prognosis, 417 
symptoms, 412 
treatment, 415 
cachecticorum, 413 
from arsenic, 415 
uterinum, 413 
Chloral-camphor, 92, 100 
Chorionitis, 468 
Chromidrosis, 109 

Chronic pustular dermatitis, etc., 202 
Cicatrices, 60 
Cicatricial keloid, 524 
diagnosis, 525 
etiology, 524 
pathology, 524 
prognosis, 525 
symptoms, 524 
treatment, 525 
Cicatrix, 525 

diagnosis, 527 
etiology, 527 
pathology, 527 
symptoms, 525 
treatment, 528 
Cimex lectularius, 782 
Cimicides, 783 

Circumscribed persistent oedema, 466 
Claret-stain, 545 
Classification, 96 
Clavus, 435 
! Clou de Biskra, 223 
! Coccogenous and bacillogenous derma- 
toses, 211 
sycoses, 226 
Coil-glands, 43 
Cold sores, 241 
Collodion, 89 
Colloid metamorphosis of the skin, 542 

milium, 542 
Collo'idome miliaire, 542 
Colored sweat, 109 
Comedo, 126 

etiology, 127 
pathology, 128 
prognosis, 131 
symptoms, 126 
treatment, 129 
extractor, 130 
Condyloma, 439, 607, 618 
Confluent variola, 153 
Congelatio, 190 
Congenital alopecia, 495 

fibro-sebaceous disease, 137 
Consecutive lesions, 58 
! Contagious follicular keratoses, 425 
Copper-nose, 482 
Cor, 435 
Corium, 21 
\ Corn, 435 
Come de la peau, 436 
Cornu cutaneum, 436 
Corpuscles of Meissner, 33 



790 



INDEX. 



Corpuscles of Vater, 31 

of Wagner, 33 
Cortical, substance of hair shaft, 40 
Cosme's paste, 678 
Coster's paste, 733 
Couperose, 384 
Cow-pox, 157 
Crab-louse, 780 
Crateriform ulcer, 666 
Craw-craw, 769 
Cretinoid oedema, 709 
Crusta lactea, 115 
Crustse, 58 
Crusts, 58 
Culex pipiens, 784 
Cuniculus of scabies, 755 
Curtrebra, 773 

Cutaneous psorospermosis, 672 
Cuticle, 24 
Cutis vera, 21 
Cyst, 132 

Cysticercus cellulosse cutis, 769 
Cysts, multiple dermoid, 137 



DACTYLITIS, tuberculous, 569 
Dandruff, 113 
Decolor ization des ongles, 516 
Deficiency of hair, 494 
Definition of terms, 62 
Defluvium capillorum, 494 
Delhi boil, 223 
Demodex folliculorum, 765 
Depilatories, 463 
Derma, 21 
Dermatalgia, 705 
Dermatitis, 184 
calorica, 189 

chronic pustular, etc., 202 
contusiformis, 170 
exfoliativa, 277, 280 
diagnosis, 279 
etiology, 279 
pathology, 279 
prognosis, 280 
symptoms, 277 
treatment, 279 
exfoliativa infantum, 280 

epidemic, 286 
gangrenosa, 202 

infantum, 202 
herpetiformis, 253 
etiology, 255 
pathology, 255 
prognosis, 255 
symptoms, 253 
treatment, 255 
medicamentosa, 192 
papillaris capillitii, 222, 511 
repens, 367 
traumatica, 185 
venenata, 185 
Dermatobia noxalis, 773 
Dermatological instruments, 93 



Dermatolymphangioma, 551 
Dermatolysis, 531 
Dermatosclerosis, 468 
Dermatoses, bacillogenous, 211 

coccogenous, 211 

of the scrofulous, 569 
Dermatosis Kaposi, 553 
Dermoid cysts, multiple, 137 
Desquamative scarlatiniform ervthema, 

165 
Diabetides, 308 

genitales, 353 
Diagnosis, general, 70 
Digiti mortui, 203 
Dipterous larvae in and beneath the 

skin, 772 
Diseases of the sebaceous glands, 113 

of the skin, 101 
Disorders of the glands, 101 
Dissection tubercle, 564 
Disseminated ringworm, 729 
Distoma hepaticum, 770 
Donda Ndugu, 486 
Dondas, 488 

Dracunculus medinensis, 767 
Dysidrosis, 112, 255 



ECCHYMOSES, 404 
Ecchymomata, 404 
Echinococcus, 770 
Ecphyma, 530 
Ecthyma, 238 

diagnosis, 240 
etiology, 239 
pathology, 239 
prognosis, 241 
symptoms, 238 
treatment, 240 

gangrenous infantile, 202 
Eczema, 297 
Eczema, 297 

diagnosis, 314 
etiology, 309 
pathology, 312 
prognosis, 340 
symptoms, 297 
treatment, 321 

acute, 305 

ani, 355 

aurium, 347 

barbe, 350 

capillitii, 340 

capitis, 340 

chronic, 306 

crurale, 359 

diabeticorum, 308 

erythematosum, 298 

faciei, 343 

fissum, 304 

genitalium, 352 

impetiginodes, 302 

intertrigo, 304 

labiorum, 345 



INDEX. 



791 



Eczema, lichenodes, 299 
local varieties, 340 
madidans, 303 
mammae, 357 
nianuum, 361 
marginatum, 309, 721 
membrorum, 359 
narium, 346 
of anns, 355 
of beard, 350 
of ears, 347 
of extremities, 359 
of face, 343 
of genital organs, 352 
of hands and feet, 361 
of lids, 349 
of lips, 345 
of nails, 364 

of nipple and breast, 357 
of nostrils, 346 
of scalp, 340 
of tropics, 365 
of umbilicus, 358 
palpebrarum, 349 
papulosum, 299 
parasitic, 367 
parasiticum, 308 
pedum, 361 
pustulosum, 302 
rhagadiforme, 304 
rubrum, 303 
sclerosum, 304 
seborrhoicum, 118, 306 
solare, 365 
squamous, 304 
tuberculatum, 691 
tuberculous, 571 
tuberculous, of nurslings, 308 
umbilici, 358 
unguium, 364 
universal, 367 
verrucosum, 304 
vesiculosum, 300 
Eczematoid epitheliomatosis of nipple, 

672 
Elementary lesions, 53 
Elephantiasis, 475 

diagnosis, 480 

etiology, 479 

pathology, 479 

prognosis, 481 

symptoms, 476 

treatment, 480 
Arabum, 475 
Grascorurn, 649 
nee void, 478 
telangiectasic, 478 
Elephant leg, 475 
Ephelis, 407 
Ephidrosis, 101 
Epidemic erythema, 664 

exfoliative dermatitis, 286 
skin disease, 286 
Epidermis, 24 



Epilation, 718 
Epithelial cancer, 665 
Epithelialkrebs, 665 
Epithelioma, 665 

diagnosis, 676 

etiology, 673 

pathology, 672 

prognosis, 680 

symptoms, 665, 672 

treatment, 677 
benign cystic, 683 
deep, 666 
discoid, 665 
papillary, 667 
pigmentary, 555 
superficial, 665 
tuberculated, QQQ 
Equinia, 220 

etiology, 221 
pathology, 221 
prognosis, 222 
symptoms, 220 
treatment, 222 
Erb grind ', 712 
Erectores pilorum, 35 
Eruptions, feigned, 201 
Erysipelas, 204 

diagnosis, 208 

etiology, 207 

pathology, 20S 

prognosis, 210 

symptoms, 204 

treatment, 208 
ambulans, 205 
chronic, 206 
Lombardy, 662 
Erythanthema syphiliticum, 617 
Erythanthemata, 61 
Erythema annularis, 169 
bullosum, 171 
caloricum, 162 
circinatum, 169 
diphtheriticum, 171 
epidemic, 664 
figuratum, 169 
gangrsenosum, 163 
idiopathic, 162 
intertrigo, 166 

diagnosis, 167 

etiology, 167 

symptoms, 166 

treatment, 167 
iris, 169 
lseve, 164 
marginatum, 170 
multiforme, 169 

diagnosis, 173 

etiology, 172 

pathology, 172 

symptoms, 169 

treatment, 174 
nodosum, 170 
noueux, 170 
papulatum, 171 



792 



INDEX. 



Erythema, papillosum, 171 

paratrimma, 164 

pernio, 164 

punctatum, 165 

scarlatiniforme, 165 

simplex, 162 

diagnosis, 165 
treatment, 165 

symptomatic, 162 

traumatic, 162 

urticatum, 171 

venenatum, 163 

vesiculosum, 171 
Erythematous syphilide, 600 
Erytheme, 162 

centrifuge, 582 

infectueux, 165 
Erythrasma, 751 

diagnosis, 753 

etiology, 752 

pathology, 752 

symptoms, 751 

treatment, 753 
Esthiomene, 564 
Etiology, general, 64 
Exanthemata, 138 
Excoriations, 59 
Exfoliative dermatitis, 277 



FALSE alopecia areata, 509 
Farcin, 220 
Farcy, 220 
Fat cushion, 46 
columns, 47 
tissue, 20 
Favic onychomycosis, 714 
Favus, 712 

of nail, 714 
Feigned eruptions, 201 
Feigwarze, 618 
Fetid sweat, 108 
Feuergurtel, 246 
Fibroma, 528 

diagnosis, 532 
etiology, 531 
pathology, 531 
prognosis, 533 
symptoms, 528 
treatment, 533 
fungoides, 691 
molluscum, 528 
Fibromyoma, 543 

Fibro-sebaceous disease, congenital, 137 
Ficosis, 226 

Filaria medinensis, 767 
diagnosis, 768 
etiology, 767 
pathology, 768 
prognosis, 769 
symptoms, 767 
treatment, 768 
sanguinis, 767 
hominis, 479 



Fischschuppenausschlag, 449 
Fish-oil, 90 
Fish -skin disease, 449 
Fissures, 60 
Flea, 766 
Fleckenmal, 446 
Fluke, liver, 770 

Folliculites etperifolliculites decalvantes, 
^508 

destructives, etc., 508 
Folliculitis barbae, 226 
Fragilitas crinium, 511 
Framboesia, 484 
Freckles, 411 
Freezing, effects of, 190 
French measles, 142 
Frost-itch, 703 
Fungous foot of India, 743 
Furunculus, 20, 211 

diagnosis, 213 

etiology, 212 

pathology, 212 

prognosis, 214 

symptoms, 211 

treatment, 213 



GAD-FLY, 772 
Gafsa button, 223 
Gale, 754 

Gangrene foudroyante, 225 
Gangrene of the extremities, symmet- 
rical, 203 

of the skin, 202 
in adults, 203 
in infants, 202 

spontaneous, 202 
Gangrenous infantile ecthyma, 202 
Gefassmal , 545 
General diagnosis, 70 

etiology, 64 

prognosis, 75 

symptomatology, 52 

therapeutics, 77 
German measles, 142 
Giant swelling, 177 
Glanders, 220 
Glands, disorders of, 101 

sebaceous diseases of, 113 
Glossy fingers, 472, 520 

skin, 520 
Glycerole of the subacetate of lead, 

338 
Glycosuric xanthoma, 539 
Gnats, 784 
Goa powder, 273 
Granular layer, 27 
Granuloma sarcomatodes, 691 

fungoides, 691 
Grubs, 772 
Grutum, 132 
Guinea-worm, 767 
Gune, 742 
Gutta rosea, 384, 482 



INDEX, 



793 



HAAKSACKMILBE, 765 
Haematidrosis, 112 
Haemophilia, 408 
Haemorrhages, 404 
Hemorrhagic variola, 152 
Hairiness, 458 
Hair-follicle, 37 

-pouch, 37 
Hairs, 35 
Harvest bug, 770 
Hautfinne, 372 
Hauthorn, 436 
Hautrbthe, 162 
Hautsclerem, 468 
Head louse, 774 
Hebra's diachylon salve, 333 
Hedge-hog skin, 451 
Hemiatrophia facialis, 472 
Hemizona, 246 
Herpes, 241 

desquamans, 742 

facialis, 241 

febrilis, 241 

gestationis, 245 

iris, 169, 244 

prseputialis, 242 

progenitalis, 242 

tonsurans, 727 

desguamatif, 742 
maculosus, 276 

zoster, 246 

diagnosis, 251 
etiology, 249 
pathology, 249 
prognosis, 252 
symptoms, 246 
treatment, 251 
Hide-bound skin, 468 
Hirsuties, 458 
Hives, 174 
Hoariness, 492 
Honeycomb ringworm, 712 
Horn," 436 
Horn-pox, 152 
Horny layer, 28 
Hiihnerauge, 435 
Hyaloma, 542 
Hyalom cler haut, 542 
Hybrid measles, 142 
Hydroa, 403 
Hydroa bulleux, 403 

vacciniforme, 403 

vesicitleux, 403 
of JBazin, 170 
Hydroadenitis, 212 
Hydroadenome emptif, 683 
Hydrosis, 101 
Hypersesthesia, 695 
Hy perh idrosis, 101 
Hyperidrosis, 101 

etiology, 102 

pathology, 103 

symptoms, 101 

treatment, 103 



Hyperkeratosis striata et follicularis, 425 
Hypertrichosis, 458 
etiology, 460 
symptoms, 458-460 
treatment, 461 
neurotica, 460 
Hypertrophic cicatrix, 524 

scar, 524 
Hypertrophy of the hair, 458 
of muscular tissue, 543 
of vessels, 544 
Hyphogenous sycosis, 226, 735 
Hypoderma, 773 



TCHTHYOL, 90 
1 Ichthyose, 449 
Ichthyosis, 449 

diagnosis, 453 
etiology, 452 
pathology, 452 
prognosis, 454 
symptoms, 449 
treatment, 454 
congenita, 451 
follicularis, 421 
hystrix, 450 
lingua], 451, 683 
nacrea, 451 
nigricans, 451 
palmaris et plantaris, 423 
serpentina, 451 
simplex, 449 
Idrosis, 101 
Ignes sacer, 246 
Impetigo, 234 

diagnosis, 235 
etiology, 235 
pathology, 235 
symptoms, 234 
treatment, 236 
contagiosa, 236 
diagnosis, 238 
etiology, 237 
pathology, 237 
symptoms, 236 
treatment, 238 
eczematodes, 302 
figurata, 303 
herpetiformis, 391 
diagnosis, 392 
etiology, 391 
pathology, 391 
prognosis, 392 
symptoms, 391 
treatment, 392 
Inflammation, 138 

Inflammatory fungoid neoplasm, 691 
Inner root-sheath of hair, 39 
Insects attacking the skin, 784 
Intertrigo, 166 
Iodized phenol, 338 
Itch mite, 754 
Ittiosi, 449 



794 INDEX 






Ixodes, 773 

Americanus, 773 
bovis, 773 
humanus, 773 
marginatus, 773 
ricinus, 773 
unipunctatus, 773 

JACOB'S ulcer, 666 
fJ Jequirity, 91 
Jigger, 765 

KAHLHEIT, 494 
Kakerlaken, 488 
Kelis, 522 
Keloid, 522 

diagnosis, 525 
etiology, 524 
pathology, 524 
prognosis, 525 
symptoms,. 523 
treatment, 525 
acne, 375 

cicatricial, 522, 524 
false, 522 
of Addison, 469 
-scar, 524 
spontaneous. 522 
spurious, 522 
Keratodermia of the extremities, sym- 
metrical, 423 
palmaris et plantaris, 423 
Kerato-hyalin, 27 
Keratoma, 432 

of palms and soles, congenital, 423 
Keratosis, 417 

follicularis, 421 
diagnosis, 423 
etiology, 422 
pathology, 423 
symptoms, 421 
treatment, 423 
contagiosa, 425 
pigmentosa, 440 
pilaris, 420 

diagnosis, 420 
etiology, 419 
pathology, 419 
symptoms, 418 
treatment, 420 
senilis, 421 
Kerion Celsi, 734 
Klamann's dusting powder, 168 
Knollenkrebs, 522 
Kratze, 754 
Kraurosis vulvse, 521 
Krithoptes monunguiculosus, 772 
Kupferfinne, 384 
Jfupferrose, 384 

T AFA tokelau, 743 
JL Lanolin, 8.8 
La perleche, 753 



La peta, 742 
La rosa, 662 
Lassar paste, 332 
Lax skin, 531 
Leiomyomata, 543 
Lenticular cancer, 680 
Lentigo, 411 

etiology, 411 
pathology, 412 
symptoms, 411 
treatment, 412 
epitheliomatous, 555 
Leontiasis, 649 
Lepothrix, 514 
Lepra, 257, 649 

diagnosis, 560 
etiology, 656 
pathology, 658 
prognosis, 662 
symptoms, 649 
treatment, 661 
ansesthetica, 653 
Arabum, 649 
maculosa, 653 
tuberosa, 650 
Lepre, 649 
Leprosy, 649 

Lombardy, 662 
nodulated, 650 
tuberculated, 650 
Leptus, 770 

autumnalis, 770 
irritans, 771 
Lesions, consecutive, 58 

elementary, 53 
Leucasmus, 487 
Leucoderma, 487 

symptoms, 487 
Leucokeratosis buccalis, 683 
diagnosis, 685 
etiology, 684 
pathology, 685 
prognosis, 686 
symptoms, 683 
treatment, 685 
Leucoplakia buccalis, 260, 683 
Leucoplasia, 683 
Leucoplasie, 451 
Lice, 774 

Lichen acuminatus, 288 
eczematodes, 299 
hypertrophicus, 560 
moniliformis, 290 
obtusus, 290 
papillosus, 560 
pilaris, 418 
planus, 289 
planus corneus, 294 
planus, of America, 292 
diagnosis, 296 
etiology, 294 
pathology, 295 
prognosis, 296 
symptoms, 292 



INDEX. 



795 



Lichen planus, treatment, 296 
psoriasis, 284 
ruber,288 

diagnosis, 290 
etiology, 290 
pathology, 291 
prognosis, 292 
symptoms, 288 
treatment, 291 
simplex, 299 
scrofulosorum, 570 
tropicus, 365 
Liodermia cum melanosi et telangiectasia, 

553 
Lip and mouth disease with fatal termina- 
tion, 708 
Liquor picis alkalinus, 335 
Liver fluke, 770 
Lombardy erysipelas, 662 

leprosy, 662 
Louse, body, 777 
clothing, 777 
crab, 780 
head, 774 
pubic, 780 
Lousiness, 774 
Lucilia Caesar, 773 
Lumberman's itch, 704 
"Lumpy jaw," 745 
Lupoid sycosis, 510 
Lupus demisclereux de la langue, 563 
Lupus elephantiacus, 560 
elevatus, 559 
erythematodes, 582 
erythematosus, 582 

diagnosis, 587 
etiology, 586 
pathology, 586 
prognosis, 590 
symptoms, 582 
treatment, 588 
in tuberculosis, 591 
exfoliativus, 560 
exuberans, 569 
exulcerans, 561 
fibrosus, 560 
fungoides, 561 
fungosus, 561 
gangrsenosus, 561 
keloides, 561 
maculosus, 559 
nodosus, 559 
non-exedens, 559, 582 
non-ulcerosus, 559 
cedematosus, 560 
of ears, 562 
of external genital organs of women, 

564 
of extremities, 562 
of face, 561 
of genital region, 562 
of mucous membranes, 563 
of trunk, 562 
planus, 559 



Lupus, profundus, 561 

psoriasiforme, 560 

psoriasis, 560 

rodens, 561 
Lupus sclereux, 560 
Lupus sclerosus, 560 

sebaceus, 582 

serpiginosus, 561 

superlicialis, 561, 582 

tuberculatus, 559 

tumidus, 559 

vegetans, 561 

vulgaris, 559 

symptoms, 559 
Lymphadenectasia, 553 
Lymphadenie cutanee, 691 
Lymphangiectasic fibromyoma, 544 
Lymph angiectasis cutis, 551 

suppurative, tubercular, 569 
Lymphangiectodes, 551 
Lymphangioma, 551 

cavernous, 552 

circumscribed, 552 

tuberosum multiplex, 552 
Lymphatic vessels of the skin, 29 
Lymphodermia perniciosa, 691 
Lymph scrotum, 470 

spaces, 29 
Lyomyomata, 543 



MACULAE, 53 
Macules, 53 
Madura foot, 743 
Malabar ulcer, 224 
Mat de Los pintos, 754 
Maliasmus, 220 

Malignant papillary dermatitis, 357, 672 
Malignant pustule, 218 
Mai per for ant dn pied, 433 
Mai roxo, 662 
Malum perforans pedis, 433 
Marsden's paste, 678 

McCall Anderson's dusting powder, 168 
Measles, 138 

black, 152 

French, 142 

German, 142 

hybrid, 142 
Medicinal rashes, 192 
Medullary substance of hair-shaft, 40 
Medullated nerve fibres, 30 
Melanoderma cachecticorum, 413 
Melano-sarcoma, 686 
Melanosis lenticularis progressiva, 553 
Melanotic carcinoma, 682 

whitlow, 687 
Mellitagra, 303 
Mentagra, 226 

parasitica, 735 
Mercurial fumigation, 637 

injection, 638 

inunction, 636 
Mercury and its compounds, 91 



796 



INDEX. 



Mercury in cutaneous disorders, 80 

Midges, 784 

Miliare scrofuleuse, 389 

Miliaria crystallina, 105 

Miliary fever, 106 

Milium, 132 

diagnosis, 133 
etiology, 132 
pathology, 133 
symptoms, 132 
treatment, 133 
Milk crust, 115 
Mitesser, 126 
Moist wart, 439 
Molluscum contagiosum, 426 
epitheliale, 426 
diagnosis, 430 
etiology, 428 
pathology, 428 
prognosis, 431 
symptoms, 426 
treatment, 431 
pendulum, 528 
sebaceum, 426 
verrucosum, 426 
Monilethrix, 513 
Moniliform hairs, 513 
Morve, 220 
Morbilli, 138 
Morbus maculosus Werlhofii, 403 

pediculosis, 774 
Morphoea, 469 

diagnosis, 473 
etiology, 472 
pathology, 473 
prognosis, 475 
symptoms, 470 
treatment, 474 
Morpion, 780 
Morvan's disease, 475 
Mosquitoes, 784 
Mother's marks, 546 
Mower's mite, 770 
Mucous layer, 25 

patch, 607, 618 
Mulberry mark, 546 
Multiple benign tumor like new growths, 
521 
cutaneous tumor, 443 
dermoid cysts, 137 

disseminated gangrene of the skin 
in infants, 202 
Muscida?, 773 
Muscles, 34 
Mycetoma, 743 
Mycosis framboesioides, 484 
fungoides, 691 

diagnosis, 694 
etiology, 693 
pathology, 693 
prognosis, 694 
symptoms, 691 
treatment, 694 
Myoma telangiectodes, 544 



Myringomycosis, 751 
Myxoedema, 709 
diagnosis, 711 
etiology, 710 
pathology, 710 
symptoms, 710 
treatment, 711 



V[ JEVOID elephantiasis, 478 
IN Nsevus araneus, 546 

fiammeus, 545, 546 

lipomatoses, 446 

lupus, 550 

mollusciformis, 446 

pigmentosus, 446 
pathology, 447 

pilosus, 446 

spilus, 446 

sanguineus, 545 

vasculosus, 545 

verrucosus, 446 

vinosus, 546 
Nail-fold, 51 
plate, 50 
Naphthol, 91 
Natal sore, 223 
Nerves of the skin, 30 
Nervous papillae, 24 
Nesselfieber, 174 
Nesselsuch, 174 
Nettle-rash, 174 
Neuroma, 533 
Neuropathic plica, 460 
Neurosis, 695 
New growths, 522 
Nigita, 765 

Nodose swellings of shafts of hairs, 513 
Nodositas crinium, 512 
Noli me tangere, 666 
Non-medullated fibres, 30 
Non-parasitic sycosis, 226 
Non-striated muscular fibres, 35 

OBJECTIVE symptoms, 52 
Odorous emanations from the skin, 
48 
(Edema, acute circumscribed, 177 
non-inflammatory, 177 
purulent, 225 
angeioneurotic, 177 
cretinoid, 709 
neonatorum, 464 
diagnosis, 465 
etiology, 465 
pathology, 465 
prognosis, 465 
symptoms, 464 
treatment, 465 
OEil de perdrix, 435 
(Estrida?, 773 
(Estrus bo vis, 772 
" Ohio scratches," 704 



INDEX, 



797 



Oleates, 89 
Onychatrophie, 516 
Onychauxis, 455 

etiology, 456 

pathology, 456 

prognosis, 457 

symptoms, 455 

treatment, 457 
Onychia syphilitica, 455 
Onychomycosis, 455, 721 
Oriental boil, 223 

lotion, 382 
Osmidrosis, 108 
Outer root-sheath of hair, 38 
Over-fatty soaps, 85 



PACHYDEKMATOCELE, 531 
Pachydermia, 475 
Pacinian corpuscles, 31 
Paget's disease, 357, 672 

diagnosis, 673 

prognosis, 673 

treatment, 673 
Papilla? of the skin, 23 
Papillary epithelioma, 667 
Papilloma, 445 
Papula?, 54 
Papules, 54 

Papulose jilarienne, 769 
Parakeratosis scutularis, 426 

variegata, 287 
Parangi, 485 

Parasitare Barffinne, 735 
Parasitic affections, 711 

eczema, 367 
Pars papillaris, 23 
reticularis, 22 
Pastes, 86 
Pediculi and acari transferred to man 

from lower animals, 782 
Pediculidae, 774 
Pediculosis, 774 
capillitii, 774 

diagnosis, 776 

symptoms, 774 

treatment, 776 
corporis, 777 

diagnosis, 779 

symptoms, 777 

treatment, 780 
pubis, 780 

diagnosis, 781 

treatment, 782 
Pediculus vestimenti, 777 
Pelade, 501 

Peliosis rheumatica, 406 
Pellagra, 662 
Pemphigus, 392 

diagnosis, 400 

etiology, 399 

pathology, 400 

prognosis, 403, 

symptoms, 393, 399 



Pemphigus, treatment, 402 
acute, 393 

acutus contagiosus adultorum, 236 
benignus, 395 
chronic, 394 
circinatus, 394 
disseminatus, 394 
foliaceus, 396 
gangrsenosus, 202 
haemorrhagicus, 394 
hystericus, 245 
malignus, 395 
neonatorum, 397 
of young girls, 397 
pruriginosus, 395 
solitarius, 395 
vegetans, 398 
virginum, 397 
vulgaris, 394 
Perforating ulcer of foot, 433 
Periodic swelling, 177 
Pernio, 164, 190 
Peruvian wart, 486 
Petechia?, 405 
Phagedena tropica, 224 
Phenol camphor, 92 
Phlegmona diffusa, 225 
Phtheiriasis. 774 
Phymata, 56 

Physiologv of the skin, 17 
Pian, 484 " 

fongoide, 691 
ruboides, of Alibert, 232 
Piedra, 515 
Pied tabetique, 708 
Pigment, 34 

atrophies, 487 
Pigmentary moles, 446 

syphilide, 603 
Pigmented carcinoma, 682 
Pili annulati, 513 
Pinta disease, 754 
Pityriasis capitis, 499 
circinata, 276 
maculata et circinata, 276 
diagnosis, 277 
etiology, 277 
pathology, 277 
symptoms, 276 
treatment, 277 
pilaris, 418 
rosea, 276 
rubra, 280^ 

diagnosis, 283 
etiology, 282 
pathology, 282 
prognosis, 284 
symptoms, 280 
treatment, 284 
aigu, 280 
pilaris, 284 

diagnosis, 285 
etiology, 285 
pathology, 285 



798 



INDEX 



Pityriasis rubra pilaris, prognosis, 286 
symptoms, 284 
treatment, 286 
Plaques jaundtres des paupieres, 535 

muqueuses, 607, 618 
Plasters, 88 
Plica Polonica, 460 
Podelcoma, 743 
diagnosis, 744 
etiology, 744 
pathology, 744 
prognosis, 744 
symptoms, 743 
treatment, 744 
Polls accidentels, 458 
Poison ivy, 185-187 
Poison oak, 185-187 
Poliosis, 492 

circumscripta, 489 
Polio thrix, 492 
Polyidrosis, 101 
Polypapilloma tropica, 484 
Polytrichia, 458 
Pomphi, 55 
Pompholyx, 255, 392 
diagnosis, 256 
pathology, 256 
symptoms, 256 
treatment, 257 
Porcupine skin, 451 
Porrigo contagiosa, 236 
larvalis, 236, 303 
decalvans, 501 
favosa, 712 
Port-wine mark, 545 
Post-mortem tubercle, 564 
Poultices, 88 
Powders, 87 
Prairie itch, 704 

Precautions to be observed in treating 
tinea favosa and tinea trichophytina, 
741 
Premature alopecia, 496 
Pre-senile alopecia, 496 
Prickle-cells, 26 

-layer, 25 
Prickly heat, 365 
Prognosis, general, 75 
Prurigo, 368, 703 

diagnosis, 371 
etiology, 370 
pathology, 370 
prognosis, 371 
symptoms, 368 
treatment, 371 
agria, 368 
ferox, 368 
hyemalis, 703 
mitis, 368 
winter, 703 
Pruritus, 695 

diagnosis, 698 
etiology, 697 
pathology, 698 



Pruritus, prognosis, 703 
symptoms, 695 
treatment, 699 
ani, 697 
genitalium, 697 
hiemalis, 703 
narium, 697 
palmee et plantse, 697 
Pseudo-pelade, 509 
Psora, 257 
Psoriasis, 257 

diagnosis, 263 
etiology, 260 
pathology, 261 
prognosis, 275 
symptoms, 257 
treatment, 266 
circinata, 257 
diffusa, 257 
figurata, 257 
guttata, 257 
gyrata, 257 
lingual, 260, 683 
nummularis, 257 
of tongue, 451 
orbicularis, 257 
punctata, 257 
Psorospermose folliculaire vegetante, 

421 
Psorospermosis, 421 
cutaneous, 672 
Ptomaines, 222 
Pubic louse, 780 
Pulex irritans, 766 
penetrans, 765 
Purpura, 405 

etiology, 409 
pathology, 409 
prognosis, 410 
symptoms, 405-408 
treatment, 410 
due to local causes, 409 
hemorrhagica, 407 
primary infectious, 408 
pulicosa, 408 
rheumatica, 406 
scorbutica, 407 
secondary infectious, 408 
simplex, 405 
symptomatic, 409 
urticans, 405 
urticata, 176 
Pustulse, 57 
Pustule, malignant, 218 

malign e, 218 
Pustules, 57 

and other lesions resulting from 

wounds, 222 
from cadaveric infection, 222 



Q 



UINQUAUD'S disease, 510 



INDEX. 



799 



RARE consequences of sebaceous cystic 
disease, 137 
Rashes, medicinal, 192 
Ray fungus, 744 
Raynaud's disease, 203, 708 
Recurrent fibroid of the skin, 689 
Relaxed skin, 531 
Resorcin, 90 
Rete Malpighianum, 25 

Malpighii, 25 

mucosum, 25 
Rhagades, 60 
Rhinophyma, 385, 483 
Rhinosceros skin, 451 
Rhinoscleroma, 556 

diagnosis, 557 

etiology, 556 

pathology, 556 

prognosis, 558 

symptoms, 556 

treatment, 557 
Rhus toxicodendron, 362 

rash produced by, 185-187 
Rhynchotta, 774 
Rhynocoprion penetrans, 765 
Ringworm, 720 

Bowditch Island, 742 

Burmese, 742 

disseminated, 729 

honeycomb, 712 

of beard, 735 

of scalp, 727 

Tokelau, 742 
Risipola Lombarda, 662 
Rodent ulcer, 665, 666 
Root of hair, 39 
Root-sheaths of hairs, 37 
Rosacea, 384, 482 

diagnosis, 483 
etiology, 483 
pathology, 483 
prognosis, 484 
symptoms, 482 
treatment, 484 

erythematosa, 482 

hypertrophica, 483 

scarlatiniforme, 165 

syphilitica, 600 
Rose-rash, 162 
Rotheln, 142 
Rotzkrankheit, 220 
Roaget, 770 
Rubella, 142 
Rubeola, 138 
Rumex ointment, 382 
Rupia escharotica, 202 



C AND-FLEA, 765 
U Sarcoma cutis, 686 

diagnosis, 690 
etiologv, 689 
pathology, 689 
prognosis, 690 



Sarcoma cutis, symptoms, 686 
treatment, 690 
idiopathic multiple pigmented, 688 
generalized primary non- melanotic, 

688 
primary melanotic, 686 
primary non-melanotic, 687 
Sarcomatosis generalis, 691 
Sarcophila Wohlfati, 773 
Sarcopsylla Westwood, 765 
Sartian disease, 662 
Satyriasis, 649 
Sayill's disease, 286 
Scabies, 754 

diagnosis, 761 
etiology, 760 
pathology, 760 
symptoms, 754 
treatment, 763 
Norvegica, 759 
Scales, 58 
Scaly patches, 619 
Scarf-skin, 24 
Scarlatina, 143 
Scarlatiniform typhus, 145 
Scarlatinoid erythema, 165 
Scartatinoide, 165 
Scarlet feyer, 143 
rash, 143, 165 
Scars, 60 

Scheerende flechte, 727 
Schleimhautpapel, 618 
Schmeerfluss, 113 
Schuppenflechte, 257 
Scirrhous cancer, 680 
Sclerema adultorum, 468 
neonatorum, 467 
etiology, 467 
pathology, 468 
symptoms, 467 
treatment, 468 
Sclererne des nouveau-nes, 467 
Scleriasis, 468 
Sclerodactylie, 472 
Scleroderma, 468 

diagnosis, 473 
etiology, 472 
pathology, 473 
prognosis, 475 
symptoms, 475 
treatment, 474 
circumscribed, 469 
diffused symmetrical, 468 
neonatorum, 467 
Sclerodermic, 468 
Scrofula, 567 

Scrofulide erythemcteuse, 582 
Scrofuloderm, large pustular, 571 

small pustular, 570 
Scrofuloderma, 567 
"Scrofulous ringworm," 582 
Scurvy, 407 
Sebaceous flux, 113 
glands, 41 



800 



INDEX. 



Sebaceous glands, diseases of, 113 
Seborrhagia, 113 
Seborrhoea, 113 

diagnosis, 119 
etiology, 118 
pathology, 119 
prognosis, 125 
symptoms, 113 
treatment, 121 

capillitii, 114 

congestiva, 118, 582 

faciei, 116 

generalis, 117, 

genitalium, 116 

oleosa, 117 

sicca, 114 

squamosa, 114 

trunci, 116 
Senile alopecia, 496 
Septum lucidum, of Oehl, 27 
Shaft of hair, 39 
Shingles, 246 
Simulia, 784 
Sirop de Gibert, 641 
Skin-worm, 129 
Smallpox, 148 
Smokers' patches, 260, 683 
Soaps, medicated, 85 

superfatted, 85 
Sommersp?'osse, 411 
Spedalskhed, 649 
Spider cancer, 546 
Spizen warzen, 439 
Spots, 53 

Spotted sickness, 754 
Squama?, 58 

Squire's glycerole of lead, 338 
Stains, 53 

Startin's acid mixture, 121, 379 
Steatoma, 134 

diagnosis, 135 

pathology, 135 

prognosis, 136 

symptoms, 134 

treatment, 135 
Steatorrhea, 113 
Steatozoon folliculorum, 765 
Stigmata, bleeding, 708 
Stinking sweat, 108 
Stominis calcitrans, 773 
Stratum corneum, 28 

granulosum, 27 

lucidum, 27 

mucosum, 25 
" Strawberry marks," 546 
Striated muscular fibres, 34 
Strophulus albidus, 132 
Struma, 567 
Subcutaneous tissue, 20 
Subjective symptoms, 52 
Sudamen, 105 

diagnosis, 106 

etiology, 106 

pathology, 106 



Sudamen, symptoms, 105 

treatment, 106 
Sudatoria, 101 
Sudolorrhoea, 306 
Sudoriparous glands, 43 
Suette miliaire, 106 
Sugar fungus in eczema, 308 
Sulphur, 91 
Superfatted soaps, 85 
Suppurative tubercular lymphangiectasis, 

569 
Surgical instruments, 93 
Swamp itch, 704 
Sweat, 46 

bloody, 112 
colored, 109 
glands, 43 

diseases of, 101 
-pore, 44 
stinking, 108 
Sweating, greenish, 111 
phosphorescent, 111 
sickness, 106 
Swelling, giant, 177 

periodic, 177 
Swine-pox, 152 
Sycosiform disorders, 226 
Sycosis, 226 

diagnosis, 229 
etiology, 228 
pathology, 229 
prognosis, 232 
symptoms, 227 
treatment, 230 
coccogenous, 226 
hyphogenous, 735 
lupoid, 510 
non-parasitic, 226 
parasitic, 735 
Symmetrical gangrene of the extremities, 
203 
keratoderma of palms and soles, 423 
Symptomatology, general, 52 
Synanthemata, 61 
Synovial lesions of the skin, 444 
Syphilides, palmar and plantar, 608 

pigmentary, 603 
Syphilis of the mucous surfaces, 618 

" tonic treatment," 634 
Syphilitic onychia, 455 

roseola, 600 
Syphiloderma, 591, 610 
diagnosis, 628 
etiology, 625 
pathology, 626 
prognosis, 644 
symptoms, 600 
treatment, 630 
bullosum, 613 

framboesioid condylomatous, 607 
gummatosum, 616 
hsereditarium, 621 
infantile, 621 
maculosum, 600 






INDEX 



801 



Syphiloderrna, papillosum, 604 
large acuminate, 605 

flat, 606 
small acuminate, 604 
flat, 605 
pustulosum, 610 

large accuminate, 612 

flat, 612 
small acuminate, 611 
flat, 612 
serpiginosum, 614 
tuberculosum, 614 
vesiculosum, 610 
Svpliilodermata, general characteristics 
* of, 596 



r PACHE pigmentaire, 446 
1 Tactile corpuscles, 33 
Tar, 89 

Tattooing, 415 
Teigne faveuse, 712 

tondante, 727 
Telangiectasic elephantiasis, 47* 
Telangiectasis, 546 
diagnosis, 547 
pathology, 546 
treatment, 547 
Terms, definition of, 62 
Texas mange, 704 
" The itch," 754 
The nails, 49 
Therapeutics, general, 77 
Thyroid cachexias, 710 
Ticks, 733 
Tinea barba?, 735 
circinata, 720 

diagnosis, 724 
etiology, 722 
pathology, 723 
prognosis, 727 
symptoms, 720 
treatment, 725 
decalvans, 501 
favosa, 712 

diagnosis, 717 
etiology, 714 
pathology, 715 
prognosis, 719 
symptoms, 712 
treatment, 717 
imbricata, 742 
diagnosis, 743 
etiology, 743 
pathology, 743 
prognosis, 743 
symptoms, 742 
treatment, 743 
kerion, 734 
sycosis, 735 

diagnosis, 738 
etiology, 736 
pathology, 738 
prognosis, 741 



Tinea, sycosis, symptoms, 735 
treatment, 739 
tondens, 727 
tonsurans, 727 

diagnosis, 731 
etiology, 729 
pathology, 730 
prognosis, 734 
symptoms, 728 
treatment, 732 
bald, 729 
trichophytina, 720 
unguium, 722 
versicolor, 747 
diagnosis, 749 
etiology, 748 
pathology, 748 
prognosis, 751 
symptoms, 747 
treatment, 750 
Tipulidae, 784 
Tokelau ringworm, 742 
Torula cerevisiae as a factor in skin dis- 
ease, 308 
Traumaticine, 89 
Trichauxis, 458 

Trichomycosis nodosa, 514, 515 
Trichonosis cana, 492 
Trichophytie sycosique, 735 
Trichoptilosis, 512 
Trichorrhexis nodosa, 512 
Trombidse, 770 
True skin, 21 
Tubercles, 55 
Tubercula, 55 

Tubercular disease of the foot, 743 
Tuberculin, 581 
Tuberculosis cutis, 558 

diagnosis, 577 
etiology, 571 
pathology, 573 
prognosis, 581 
symptoms, 559 
treatment, 558 
orificialis, 567 
verrucosa, 564 
Tuberculous dactylitis, 569 

eczema, 571 
Tuberose carcinoma, 682 
Tumor cavernosus, 547 
Tumores, 56 
Tumors, 56 
Tvloma, 432 
Tylosis, 432 



ULCERA, 60 
Ulcer, crateriform, 666 
Ulcers, 60 
Ulcus exedens, 666 
Ulerythema acneiforme, 375, 566 
Undescribed form of atrophy of the hair 

of the beard, 512 
Unguentum diachyli albi, of Hebra, 333 



51 



802 



INDEX. 



Uridrosis, 111 
Urticse, 55 
Urticaire, 174 
Urticaria, 174 

diagnosis, 180 
etiology, 178 
pathology, 180 
prognosis, 184 
symptoms, 174 
treatment, 181 
ab ingestis, 179 
annularis, 176 
bullosa, 176 
evanida, 176 
figurata, 176 
hsemorrhagica, 176 
papulosa, 176 
perstans, 176 
pigmentosa, 176 
diagnosis, 177 
etiology, 177 
pathology, 177 
treatment, 177 
tuberosa, 176 
vesiculosa, 176 



yACCINATION, 158 
» Vaccinia, 157 
Vagabond's disease, 782 
Varicella 155 

diagnosis, 156 

gangrenosa, 202 
Varices tymphatiques dermiques, 551 
Variola, 148 

hemorrhagic, 152 
Varioloid, 152 
Variolous erythema, 149 

roseola, 149 
Varix lymphaticus, 478 
Varus, 372 
Vascular papillae, 24 
Vasomotor and trophic neuroses, 707 
Veins of the skin, 28 
Venereal warts, 439 
Vergetures, 518 
Verruca, 439 

diagnosis, 441 
etiology, 441 
pathology, 441 
prognosis, 443 
symptoms, 439-441 
treatment, 442 

acquisita, 440 

acuminata, 439 

congenita, 440 

filiformis, 440 

glabra, 440 

necrogenica, 564 

plana, 440 

senilis, 440 

vulgaris, 440 
Verrue, 439 
Verruga Peruana, 486 



Vesicles, 56 
Vesiculse, 56 
Vespidse, 784 
Vibices, 405 
Vitiligo, 489 

diagnosis, 491 

etiology, 491 

pathology, 491 

prognosis, 492 

symptoms, 489 

treatment, 492 
Vitiligoidea, 535 
Vleminckx's solution, 84, 383 

^ WAKT-CUKES," 443 
M Warts, 439 

Warze, 439 

Wasps, 784 

Water, in cutaneous diseases, 83 

Wen, 134 

Wheals, 55 

Whisk ey-drinker's nose, 483 

White leprosy, 491 

" White spots," of nails, 516 

Wilkinson's salve, 272 

Wine drinker's nose, 483 

Winter prurigo, 703 

Wood-beetle, 773 

Wood-tick, 773 

Wool-fat, 88 



XANTHELASMA, 535 
.A Xanthelasmoidea, 176 
Xanthoma, 535 

diagnosis, 538 
etiology, 537 
pathology, 538 
prognosis, 539 
symptoms, 535 
treatment, 539 

diabeticorum, 539 
diagnosis, 540 
etiology, 540 
pathology, 540 
prognosis, 540 
symptoms, 539 
treatment, 540 

multiplex, 536 

papulatum, 536 

planum, 536 

tuberculosum, 536 

tuberosum, 536 
Xeroderma, 448, 449 

pigmentosum, 553 
Xerosis, 448 

symptoms, 448 

VAWS, 484 



r OXA, 246 
i Zoster, 246 



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Mines, N.Y., and D.W.Ward, Ph. B., Columbia 
College S:hool of Mines, N. Y., and Chas. H. 
Willmarth, M. S., N. Y. §1. 

HISTOLOQY, PATHOLOCY AND BAC- 
TERIOLOCY— By Bennett S. Beach, M D., 
Lecturer on Histology, Pathology and Bacte- 
riology, New York Polyclinic. $1. 

MATERIA MEDICA AND THERAPEU- 
TICS— By L. F. Warner, M.D., Attending 
Physician, St. Bartholomew's Disp., N. Y. St. 

PRACTICE OF MEDICINE, INCLUDING 
NERVOUS DISEASES— By Edwin T.Dou- 
bleday, M.D., Member N.Y. Pathological Soci- 
ety, and J. D. Nagel, M. D , Member N. Y. 
County Medical Association. $1. 

S U R C E R Y (Double Number)— By Bern B. Gal- 
lattdet, M. D., Visiting Surgeon, Bellevue 
Hospital, N.Y., and Charles Dixon Jones, M. D., 
Surgeon Yorkville Dispensary, N. Y. §1.75. 



CENITO - URINARY AND VENEREAL 

D I S E AS ES— By Charles H. Chetw ood, M.D., 
Visiting Surgeon, DemLt Dispensary, Dep. of 
Surg, and Gen.-Urm. Dis., New York. $1. 

DES EASES OF THE SKIN— By Charles C. 
Ransom, M. D., Assistant Dermatologist, Van- 
deroilt Clinic, New York. $1. 

DISEASES OF THE EYE, EAR, THROAT 
AND NOSE— By Frank E. Miller, M.D., 
Throat Surgeon, Vanuerbilt Clinic, New York, 
James P. McEvoy, M.D., Throat Surgeon, Belle- 
vue Hosp., Out-Patient Dep., New York, and 
J. E. Weeks, M. D., Lect. on Ophthal. and 
Otol., Belle vue Hosp., Med. Col., N. Y. $1. 

OBSTETRICS — By Charles W. Hayt, M.D., 
House Pnysician, Nursery and Child's Hospi- 
tal, New York. $1. 

CYNECOLOCY— By G. W. Bratenahl, M.D., 
Assistant in Gynecology, Yanderbilt Clinic, 
New York, and Sinclair Tousey, M. D., Assist- 
ant Surgeon, Out-Patient Department, Roose- 
velt Hospital, New York. §1. 

DISEASES OF CH I LDREN-By C.A.Rhodes, 
M. D., Instructor in Diseases of Children, New 
York Pest-Graduate Medical College. 91. 



For special circular with full information and specimen pages address the publishers. 
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Dictionaries, 



NEW EDITION. THOROUGHLY REVISED. JUST READY. 

2>ungit6on'6 HKctionanj 

OF MEDICAL SCIENCE. 

WITH THE 

Pronunciation, Accentuation and Derivation 

OK THE TERMS. 

Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology, 
Medical Chemistry, Pharmacology, Pediatrics, Pharmacy, Therapeutics, Medicine, Hy- 
giene, Dietetics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, 
Obstetrics, Medical Jurisprudence and Dentistry, etc., etc. With the Pronunciation, 
Accentuation and Derivation of the Terms. By Eobley Dunglison, M. D., late Professor 
of Institutes of Medicine in the Jefferson Medical College of Philadelphia. New (21st) 
edition, thoroughly revised and greatly enlarged by Kichakd J. Dunglison, A. M., M. D. 
In one very large and handsome royal octavo volume of 1100 pages. Cloth, $7.00; 
leather, raised bands, $8.0 f>. 

THIS great medical dictionary, which has been for more than two generations the 
standard of the English speaking race, is now, after several years of incessant 
labor, issued in a thoroughly revised and greatly enlarged and improved edition. 
The new words and phrases aggregate over 44,000 and by themselves would fill a 
large volume. Space has been gained by the excision of everything obsolete, and the 
page has been much enlarged, so that while the new edition contains far more matter than 
its predecessor, the whole is accommodated within a volume convenient for the hand. 

The revision has not only covered every word, but it has resulted in a number of 
important new features designed to confer on the work the utmost usefulness, and to make 
it answer the most advanced demands of the times. 

Pronunciation has been introduced throughout by means of a simple and obvious 
system of phonetic spelling. At a glance the proper sound of a word is clearly indicated, 
and thus a most important desideratum is supplied. 

Derivation affords the utmost aid in recollecting the meanings of words, and gives 
the power of analyzing and understanding those which are unfamiliar. It is indicated in 
the simplest manner. Greek words are spelled with English letters, and thus placed at 
the command of those unfamiliar with the Greek alphabet. 

Definitions, the essence of a dictionary, are clear and full, a characteristic in 
which this work has always been preeminent. In this edition much explanatory and 
encyclopedic matter has been added, especially upon subjects of practical value. Thus 
under the various diseases will be found their symptoms, treatment, etc. ; under drugs their 
doses and effects, etc., etc. A vast amount of information has been clearly and conveniently 
condensed into tables in the alphabet. 

The typography is thoroughly in keeping with the excellence of the literary material. 
In a word, both the editor and the publishers have felt that the world-wide reputation of 
Dunglison's Dictionary has rendered it incumbent on them to ensure that in its re- 
modelled and enlarged shape it should be found equal to all that the student and practi- 
tioner can expect from such a work. 

The National Medical Dictionary, 

Including English, French, German, Italian and Latin Technical Terms used in 
Medicine and the Collateral Sciences, and a Series of Tables of Useful Data. By John 
S. Billings, M. D., LL. D., Edin. and Harv., D. C. L., Oxon., member of the National 
Academy of Sciences, Surgeon U. S. A., etc. In two very handsome royal octavo volumes 
containing 1574 pages, with two colored plates. Per volume — cloth, $6.00 : leather, $7.00; 
half morocco, marbled edges, $8.50. For sale by subscription only. Specimen pages 
on application. Address the publishers. 



Its scope is one which will at once satisfy the 
student and meet all the requirements of the med- 
ical practitioner. Clear and comprehensive defi- 
nitions of words should form the prime feature of 
any dictionary, and in this one the chief aim 
seems to be to give the exact signification and the 
different meanings of terms in use in medicine 
and the collateral sciences in language as terse as 
is compatible with lucidity. The work is remark- 
able, too, for its fulness, it presents to the Eng- 
lish reader a thoroughly scientific mode of 
acquiring a rich vocabulary and offers an accurate 
and ready means of reference in consulting works 
in any of the three modern continental languages 



which are richest in medical literature. Apart from 
the boundless stores of information which may be 
gained by the study of a good dictionary, one is 
enabled by the work under notice to read intelli- 
gently any technical treatise in any of the four 
chief modern languages. There cannot be two 
opinions as to the great value and usefulness of 
this dictionary as a book of ready reference for all 
sorts and conditions of medical men. So far as 
we have been able to see, no subject has been 
omitted, and in respect of completeness it will be 
found distinctly superior to any medical lexicon 
yet published. — The London Lancet, April 5, 1890. 



HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used in Medicine and the 
Collateral Sciences. By Richard D. Hobltn, M. D. In one large royal 12mo. volume of 520 double- 
columned pages. Cloth, §1.50; leather, §2.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy. 



NEW (THIRTEENTH) EDITION. JUST BEADY. 

GRAY'S ANATOMY 

IN COLORS OR IN BLACK. 



Anatomy, Descriptive and Surgical, 

BY HENRY GRAY, P. R. S., 

LECTURER ON ANATOMY AT ST. GEORGE'S HOSPITAL, LONDON. 

Edited by T. PICKERING PICK, F.E. C.S., 

Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, 
Royal College of Surgeons of England. 

A new American from the thirteenth enlarged and improved London edition. _ In one 

imperial octavo volume of 1100 pages, with 635 large and elaborate engravings 

on wood. Price, with illustrations in colors, cloth, $7 ; leather, $8. 

Price, with illustrations in black, cloth, §6 ; leather, $7. 

SINCE 1857 Gray's Anatomy has been the standard work used by students of 
medicine and practitioners in all English-speaking races. So preeminent has it 
been among the many works on the subject that thirteen editions have been 
required to meet the demand. This opportunity for frequent revisions has been 
fully utilized and the work has thus been subjected to the careful scrutiny of many of the 
most distinguished anatomists of a generation, and thus a degree of completeness and ac- 
curacy has been secured which is not attainable in any other way. In no former revision 
has so much care been exercised as in the present to provide for the student all the 
assistance that a text-book can furnish. The engravings have always formed a distin- 
guishing feature of this work, and in the present edition the series has been enriched and 
rendered complete by the addition of many new ones. The large scale on which the 
illustrations are drawn and the clearness of the execution render them of unequalled 
value in affording a grasp of the complex details of the subject. As heretofore the name 
of each part is printed in the engraving, thus conveying to the eye at once the position, 
extent and relations of each organ, vessel, muscle, bone or nerve with a clearness impos- 
sible wBen figures or lines of reference are employed. Distinctive colors have been em- 
ployed to give additional prominence to the attachments of muscles, the veins, arteries 
and nerves. For the sake of those who prefer not to pay the slight increase in cost 
necessitated by the use of colors, the volume is published also in black alone. 

The illustrations thus constitute a complete and splendid series, which will greatly 
assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room. Combining as it does a complete Atlas of Anatomy 
with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers 
a more extended range of subjects than is customary in the ordinary text-books. It not 
only answers every need of the student in laying the groundwork of a thorough medical 
education, but owing to its application of anatomical details to the practice of medicine 
and surgery, it also furnishes an admirable work of reference for the active practitioner. 
A few notices of the previous edition are appended : 
Gray's standard Anatomy has been and will be I The work is published with black and colored 



for years the text-book for students. The book 
needs only to be examined to be perfectly under- 
stood. — Medical Press of Western New York. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy. 
It would be indeed difficult to name a feature 
wherein "Gray" could be mended or bettered, 
and it needs no prophet to see that the royal 
work is destined for many years to come to hold 
the first place among anatomical text-books. 



plates. It is a marvel of book-making.— American 
Practitioner and News. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language.— Cincinnati 
Medical News. 

The best work on anatomy that is published in 
any language. — Virginia Medical Monthly. 

The most popular work on anatomy ever written 
— Journal of the American Medical Association. 



Holden's Landmarks, Medical and Surgical. 

Landmarks, Medical and Surgical. By Luther Holden, F. E. C. S., 
Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Second American 
from the third and revised English edition, with additions by W. W. Keen, M. D., Pro- 
fessor of Artistic Anatomy in the Penna. Academy of Fine Arts. In one 12mo. volume 
of 148 pages. Cloth, §1.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy, Physiology, 



HUMAN MONSTROSITIES 

BY BARTON C. HIRST, M. D., and GEORGE A. PIERSOL, M. D. 



Professor of Obstetrics in the University 
of Pennsylvania. 



Professor of Anatomy and Embryology 
in the University of Pennsylvania. 



Magnificent folio, containing 220 pages of text, illustrated with engravings, and 
39 full- page, photographic plates from nature. In four parts, price, each, $5. Complete 
work just ready. Limited edition, for sale by subscription only. Address the Publishers. 

must always retain the honor of being the first of 
its kind written in the English language. — The 
British Medical Journal, May 27, 1893. 

This work promises to be one for which a place 
must be found in the library of every anatomist, 
pathologist, obstetrician and teratologist. It is the 
joint production of an obstetrician, and an embry- 
ologist, and histologist, and this fact makes it 
certain that both the obstetric and anatomical 
sides of the eubject will be fully represented and 
described. The book promises to be one of the 
greatest value to the EDglish-speaking medical 
world.— Edinburgh Medical Journal, April, 1892. 



We have before us the fourth and last part of 
the latest and best work on human monstrosi- 
ties. This completes one of the masterpieces of 
American medical literature. Typographically 
and from an artistic standpoint, the work is un- 
exceptionable. In this last acd final volume 
is presented the most complete bibliography of 
teratological literature extant. No library will be 
complete without this magnificent work. — Jour- 
nal of the American Medicat Asso., May 6, 1893. 

Altogether, Human Monstrosities is a satisfactory 
production. It will take its place as a standard 
work on teratology in medical libraries, and it 



Allen's System of Human Anatomy. 



A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. By Harrison 
Allen, M. D., Professor of Physiology in the University of Pennsylvania. With an 
Introductory Section on Histology by E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 fall page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; 
also bound in one volume, cloth, $23.00 ; very handsome half Eussia, raised bands and 
open back, $25.00. For sale by subscription only. Address the Publishers. 



Clarke & Lockwood's Dissector's Manual. 

The Dissector's Manual. By W. B. Clarke, F. B. C. S., and C. B. Lock- 
wood, F. B. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical 
School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. 
Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 



Messrs. Clarke and Lockwood have written a book 
that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best way to display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



intimate association with students could have 

fiven. With such a guide as this, accompanied 
y so attractive a commentary as Treves' Surgical 
Applied Anatomy (same series), no student could 
fail to be deeply and absorbingly interested in the 
study of anatomy.— New Orleans Medical and Sur- 
gical Journal, April, 1884. 



Treves' Surgical Applied Anatomy. 

Surgical Applied Auatomy. By Frederick Treves, F. B. C. S., Senior 
Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- 
size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, p. 30. 

Bellamy's Surgical Anatomy. 

The Student's Guide to Surgical Anatomy : Being a Description of t ne 
most Important Surgical Begions of the Human Body, and intended as an Introduction L ° 
Operative Surgery. By Edavard Bellamy, F. B. C. S., Senior Assistant- Surgeon to tlie 
Charing- Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. 



Wilson's Human Anatomy. 



A System of Human Anatomy, General and Special. By Erasmus 
Wilson, F. B. S. Edited by VV. H. (J-obrecht, M. D., Professor of General and Surgical 
Anatomy in the Medical College of Ohio. In one large and handsome octavo volume 
of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
12mo., 310 pages, 220 woodcuts. Cloth, $1.75. 

HORNER'S SPECIAL ANATOMY AND HISTOL- 



OGY. Eighth edition. In two octavo volumes 
of 1007 rages-, with 320 woodcuts. Cloth. $6.00. 
CLELAND'S DIRECTORY FOR THE DISSEC- 
TION OF THE HUMAN BODY. 12mo., 178 pp. 
Cloth, $1.25. 



Lea Brothers & Co., Publishers, 706, 708 &710 Sanson) Street, Philadelphia. 



Physics, Physiology, Anatomy, Chemistry. 



Draper's Medical Physics. 



Medical Physics. A Text-book for Students and Practitioners of Medicine. 
By John C. Draper, M. D., LL. D., Prof, of Chemistry in the Uniy. of the City of 
New York. In one octavo vol. of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 



While all enlightened physicians will agree that 
a knowledge of physics is desirable for the medi- 
cal student, only those actually engaged in the 
teaching of the primary subjects can be fully 
aware of the difficulties encountered by students 
who attempt the study of these subjects without 
a knowledge of either physics or chemistry. 
These are especially felt by the teacher of physi- 
ology. 

It "is, however, impossible for him to impart a 
knowledge of the main facts of his subject and 
establish them by reasons and experimental dem- 
onstration, and at the same time undertake to 
teach nb initio the principles of chemistry or phys- 
ics. Hence the desirability, we may say the 
necessity, for some such work as the present one. 



No man in America was better fitted than Dr. 
Draper for the task he undertook and he has pro- 
vided the student and practitioner of medicine 
with a volume at once readable and thorough. 
Even to the student who has some knowledge of 
physics this book is useful, as it shows him its 
applications to the profession that he has chosen. 
Dr. Draper, as an old teacher, knew well the diffi- 
culties to be encountered in bringing his subject 
within the grasp of the average student, and that 
he has succeeded so well proves once more that 
the man to write for and examine students is the 
one who has taught and is teaching them. The 
book is well printed and fully illustrated, and in 
every way deserves grateful recognition. — The 
Montreal Medical Journal, July, 1890. 



Power's Human Physiology.— Second Edition. 

Human Physiology. By Henry Power, M. B., F. E. C. S., Examiner in 
Physiology, Eoyal College of Surgeons of England. Second edition. In one 12mo. vol. 
of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 30. 



Robertson's Physiological Physics. 



Physiological Physics. By J. McGregor Kobertson, M. A., M. B., 
Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 
537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. 

The title of this work sufficiently explains the ments. It will be found of great value to the 
nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of 
ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- heartily recommend it.— Journal of the American 
larly useful as a guide to his laboratory experi- Medical Association, Dec. 6. 1884. 



Dalton on the Circulation of the Blood. 

Doctrines of the Circulation of the Blood. A History of Physio- 
logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. 
Dalton, M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- 
geons, New York. In one handsome 12mo. volume of 293 pages. Cloth, $2. 



Dr. Dalton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 



ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 



Bell's Comparative Anatomy and Physiology. 

Comparative Anatomy and Physiology. ByF. Jeffrey Bell, M. A., 
Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 



pages, with 229 illustrations. Limp cloth, $2. 
The manual is preeminently a student's book — 
clear and simple in language and arrangement. 
It is well and abundantly illustrated, and is read- 
able and interesting. On the whole we consider 



See Students' Series of Manuals, page 30. 
it the best work in existence in the English 
language to place in the hands of the medical 
student. — Bristol Medico- Chirurgical Journal, Mar. 
1886. 



Ellis' Demonstrations of Anatomy.— Eighth Edition. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy 
in University College, London. From the eighth and revised London edition. In one 
very handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25 ; leather, $5.25. 

Roberts' Compend of Anatomy. 

The Compend of Anatomy. For use in the dissecting-room and in pre- 
paring for examinations. By John B. Koberts, A. M., M. D., Lecturer in Anatomy in 
the University of Pennsylvania. Tn one 16mo. vol. of 196 pages. Limp cloth, 75 cents. 



WOHLER'S OUTLINES OF ORGANIC CHEM- 
ISTRY. Edited by Fittig. Translated by Ira 
Remsen, M. D , Ph. D. In one 12mo. volume of 
550 pages. Cloth, S3. 

LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 



CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henry Power. In one octavo volume. 

CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co., Pub fishers, 706, 708 &710 San so m Street, Philadelphia. 



8 



Physiology— (Continued), Chemistry, 



Foster's Physiology.— Fifth Edition. 

Text-Book of Physiology. By Michael Foster, M. D., F. E. S., Prelec- 
tor in Physiology and Fellow of Trinity College, Cambridge, England. New (fourth) and 
enlarged American from the fifth and revised English edition, with notes and additions. 
In one handsome octavo vol. of 1072 pages, with 282 illus. Cloth, $4.50; leather, $5.50. 

The appearance of another edition of Foster's 
Physiology again reminds us of the continued 
popularity of this most excellent work. There 



can be no doubt that this text-book not only con- 
tinues to lead all others in the English language, 
but that this last edition is superior to its prede- 
cessors. It is evident that the author has devoted 
a considerable amount of time and labor to its 
preparation, nearly every page bearing evidences 
of careful revision. Although the work of the 
American editor in former editions has been by 



the author largely adopted in a modified form in 
this revision, much was still left to be done by the 
editor to render the work fully adapted to the wants 
of our American students, so that the American 
edition will undoubtedly continue to supply the 
market on this side of the Atlantic. The work 
has been published in the characteristic creditable 
style of the Lea's, and owing to its enormous sale, 
is offered at an extremely low price. — The Medical 
and Surgical Reporter, Jan. 9, 1892. 



Dalton's Physiology.— Seventh Edition. 

A Treatise on Human Physiology. Designed for the use of Students 
and Practitioners of Medicine. By John C. D Alton, M. D., Professor of Physiology in 
the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly 
revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- 
tiful engravings on wood. Cloth, $5.00 ; leather, $6.00. 

have never been in any doubt as to its sterling 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



worth.— N. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage &i 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one'which we can highly recommend to all our 
readers.— Dublin Journal of Medical Science, Feb.'83. 



Chapman's Human Physiology. 



A Treatise on Human Physiology. By Henry C. Chapman, M. p., 
Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 
In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50 ; leather, $6.50. 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 



nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 
farther, and the latter will find entertainment and 
instruction in an admirable book of reference; — 
North Carolina Medical Journal, Nov. 1887. 



Schofield's Elementary Physiology.— Just Ready. 

Elementary Physiology for Students. By Alfred T. Schofield, 
M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 
227 engravings and 2 colored plates containing 30 figures. Cloth, $2.00. 

Frankland & Japp's Inorganic Chemistry. 

Inorganic Chemistry. By E. Frankland, D. C. L., F. E. S., Professor of 
Chemistry in the Normal School of Science, London., and F. B. Japp, F. I. C, Assistant 
Professor of Chemistry in the Normal School of Science, London. In one handsome 
octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 



This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry,with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 



chemical knowledge is behind the times, would 
do well to study this work. The descriptions and 
demonstrations are made so plain that there is 
no difficulty in understanding them. — Cincinnati 
Medical News, January, 1886. 



Clowes' Qualitative Analysis.— Third Edition. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. By Frank Clowes, D. Sc, London, Senior Science-Master 
at the High School, Newcastle-under-Lyme, etc. Third American from the fourth and 
revised English edition. In one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. 



CLASSEN'S ELEMENTARY QUANTITATIVE 
ANALYSIS. Translated, with notes and addi- 
tions, by Edgar F. Smith, Ph. D., Assistant Pro- 



fessor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 
pages, with 36 illus. Cloth, §2.00. 



Lea Brothers & Co.. Publishers, 70S, 708 & 710 Sansom Street, Philadelphia. 



Chemistry — (Continued). 



Simon's Chemistry.— New (4th) Edition. Just Ready. 

Manual Of Chemistry. A Guide to Lectures and Laboratory work for Begin- 
ners in Chemistry. A Text-book, specially adapfed for Students of Pharmacy and Medi- 
cine. By TV. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology in the College 
of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- 
lege of Pharmacy. New (4th) edition. In one 8vo. vol. of 490 pp., with 44 woodcuts and 
7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25. 

A work which rapidly passes to its fourth edition [ dard of comparison for tests depending on colors, 
needs no further proof of having achieved a sue- and frequently upon their changes. To the prac- 



cess. In the present case the claims to favor are 
obvious. Emanating from an experienced teacher 



titioner, who is likely to be confronted at any time 

with important pathological or toxicological ques- 

of medical and pharmaceutical students the vol- tions to be answered by the test-tube, the volume 



ume is closely adapted to their needs. This is 
shown not only by the careful selection and clear 
presentation of its subject matter, but by the 
colored plates of reactions, which form a unique 
feature. Every teacher will appreciate the saving 
of his own time, and the advantages aecruiog to 
the student from a permanent and accurate stan- 



will be of the utmost value. Such it has proved 
in the pa3t, and the author has accordingly been 
enabled, through frequent and thorough revisions 
to keep his work constantly in touch with the 
progress of its science and the best methods of its 
presentation.— Kansas City Medical Index, May, 
1893. 



Fownes' Chemistry.— Twelfth Edition. 

A Manual of Elementary Chemistry; Theoretical and Practical. By 
George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New 
American, from the twelfth English edition. In one large royal 12mo. volume of 1061 
pages, with 168 engravings and a colored plate. Cloth, $2.75 ; leather, $3.25. 

cal students. In this work are treated fully : Heat, 



Fownes' Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 



Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 
chemistry extant. — Cincinnati Med. News, Oct. '85. 



Attfield's Chemistry.— Twelfth Edition. 

Chemistry, General, Medical and Pharmaceutical; Including the 
Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the 
Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., 
Ph. D., F. I. C, F. R. S., etc., Professor of Practical Chemistry to the Pharmaceutical 
Society of Great Britain, etc. A new American, from the twelfth English edition, 
specially revised by the Author for America. In one handsome royal 12mo. volume of 



782 pages, with 88 illustrations. Cloth, $2.7 o 
Attfield's Chemistry is the most popular book 
among students of medicine and pharmacy. This 
popularity rests upon real merits. Attfield's work 
combines in the happiest manner a clear exposi- 
tion of the theory of chemistry with the practical 
application of this knowledge to the everyday 
dealings of the physician and pharmacist. His 
book is precisely what the title claims for it. The 
admirable arrangement of the text enables a 
reader to get a good idea of chemistry without 
the aid of experiments, and again it is a good 
laboratory guide, and finally it contains such a 



leather, $3.25. 
mass of well-arranged information that it will al- 
ways serve as a handy book of reference. He 
does not allow any unutilizable knowledge to slip 
into his book ; his long years of experience have 
produced a work which is both scientific and 
practical, and which shuts out everything in the 
nature of a superfluity, and therein lies the secret 
of its success. This last edition shows the marks 
of the latest progress made in chemistry and chem- 
ical teaching. — New Orleans Medical and Surgical 
Journal, Nov. 1889. 



Bloxam's Chemistry.— Fifth Edition. 

Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professor 
of Chemistry in King's College, London. New American from the fifth London 
edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 



complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 
the best manuals of general chemistry rn the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 



Luff's Manual of Chemistry.— Just Ready. 

A Manual of Chemistry. For the use of students of medicine. By Arthur 
P. Ltjef, M. D., B. Sc, Lecturer on Medical Jurisprudence and Toxicological Chemistry, 
St. Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 
engravings. Cloth, $2.00. See Students' Series of Manuals, page 30. 

Greene's Medical Chemistry. 

A Manual of Medical Chemistry. For the use of Students. By William 
H. Greene, M. D., Demonstrator of Chemistry in the Medical Department of the Uni- 
versity of Pennsylvania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson* Street, Philadelphia. 



10 Chemistry — (Continued), Pharmacy. 

Vaughan & Novy on Ptomaines and Leucomaines — 2d Edition. 

Ptomaines, Leucomaines and Bacterial Proteids ; or the Chemi- 
cal Factors in the Causation of Disease. By Victor C. Vaughan, Ph. D., 
M. D., Professor of Physiological and Pathological Chemistry, and Associate Professor of 
Therapeutics and Materia Medica in the University of Michigan, and Frederick G. 
Novy, M. D., Instructor in Hygiene and Physiological Chemistry in 1he University of 
Michigan. New (second) edition. In one handsome 12mo. vol. of 389 pages. Cloth, $2,25. 

and sanitarian. It contains information which 



This book is one that is of the greatest import- 
ance, and the modern physician who accepts 
bacterial pathology cannot have a complete 
knowledge of this subject unless he has carefully 
perused it. To the toxicologist the subject is 
alike of great import, as well as to the hygienist 



is not easily obtained elsewhere, and which is 
of a kind that no medical thinker should be 
without. — The American Journal of the Medical 
Sciences, April, 1892. 



Remsen's Theoretical Chemistry.— New (4th) Edition. 

Principles of "Theoretical Chemistry, with special reference to the Con- 
stitution of Chemical Compounds. By Ira Remsen, M. D., Ph. D., Professor of Chem- 
istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- 
tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. 

The fourth edition of Professor Remsen's well- 
known book comes again, enlarged and revised. 
Each edition has enhanced its value. We may say 
without hesitation that it is a standard work on 
the theory of chemistry, not excelled and scarcely 
equalled by any other in any 



any language. Its trans- 



lation into German and Italian speaks for its ex- 
alted position and the esteem in which it is held 
by the most prominent chemists. We claim for 
this little work a leading place in the chemical 
literature of this country. — The American Journal 
of the Medical Sciences, July, 1893. 



Charles' Physiological and Pathological Chemistry. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. By T. Cranstoun 
Charles, M. D., F. R. S., M. S., formerly Assistant Professor and Demonstrator of Chem- 
istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume 
of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the impor- nowadays. Dr. Charles has devoted much space 

tance and practical reach of his subject, and he to the elucidation ot urinary mysteries. He does 

has treated it in a competent and instructive man- this with much detail, and yet in a practical and 

ner. We cannot recommend a better book than intelligible manner. In fact, the author has filled 

the present. In fact, it fills a gap in medical text- his book with many practical hints.— Medical Reo 

books, and that is a thing which can rarely be said ord, December 20, 1884. 



Hoffmann and Powers' Medicinal Analysis. 

A Manual of Chemical Analysis, as applied to the Examination of Medi- 
cinal Chemicals and their Preparations. Being a Guide for the Determination of their 
Identity and Quality, and for the Detection of Impurities and Adulterations. For the 
use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- 
tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to 
the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- 
istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and 
much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

Parrish's Pharmacy.— Fifth Edition. 

A Treatise on Pharmacy : Designed as a Text-book for the Student, and as 
a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
By Edward Parrish, late Professor of the Theory and Practice of Pharmacy in the 
Philadelphia College of Pharmacy. Fifth edition, thoroughly revised, by Thomas S. 
Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. 
Cloth, $5.00 ; leather, $6.00. 

No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to 
himself of so useful a guide to practice, and no leave this work out of the list of their works of 
physician who properly estimates the value of an reference. The country practitioner, who must 
accurate knowledge of the remedial agents em- always be in a measure his own pharmacist, will 
ployed by him in daily practice, so far as their find it indispensable.— Louisville Medical News, 
miscibility, compatibility and most effective meth- March 29, 1884. 



Ralfe's Clinical Chemistry. 

Clinical Chemistry. By Charles H. Balfe, M. D., F. E. C. P., Assistant 
Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, 
with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



flateria fledica, Therapeutics. 



11 



Stille & Maisch's National Dispensatory.— New (5th) Edition. 

The National Dispensatory. 

Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- 
cines, including those recognized in the Pharmacopoeias of the United States, Great 
Britain and Germany, with numerous references to the French Codex. By Alfred 
Stille, M. D., LL.D., Profess 3r Emeritus of the Theory and Practice of Medicine and of 
Clinical Medicine in the University of Pennsylvania, and John M. Maisch, Phar. ~D., 
Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secre- 
tary to the American Pharmaceutical Association. New (fifth) edition, revised, and cover- 
ing the new U. S. Pharmacopoeia. In one magnificent imperial octavo volume of about 
1750 pages, with about 325 elaborate engravings. Preparing. 

A FEW NOTICES OF THE PREVIOUS EDITION ARE APPENDED. 

It is no wonder that it has become the 



The matters with which it deals are of so prac- 
tical a nature that neither the physician nor the 
pharmaceutist can do without the latest text-books 
on them, especially those that are so accurate and 
comprehensive as this one. The book is in every 
way creditable both to the authors and to the pub- 
lishers.— The New York Medical Journal, May 21, 
1887. 

The authors and publishers have reason to feel 
proud of this, the most comprehensive, elaborate 
and accurate work of the kind ever printed in this 



country. 

standard authority for both the medical and phar- 
maceutical profession, and that four editions have 
been required to supply the constant and increas- 
ing demand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 
discovery have received due attention.— Kansas 
City Medical Index, Nov. 1887. 



Maisch's Materia Medica.— New (5th) Edition. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica 
of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists 
and Physicians. By J ohn M. Maisch, Phar. D., Prof, of Materia Medica and Botany in 
the Philadelphia College of Pharmacy. New (fifth) edition, thoroughly revised. In one 
very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00. 



This is an excellent manual of organic materia 
medica, as are all the works that emanate from the 
skilful pen of such a successful teacher as John 
M. Maisch. The Dook speaks for itself in the most 
forcible language. In the edition before us which 
is the fifth one published within the comparatively 
short space of eight years (and this is the best 
proof of the great value of the work and the 
just favor with which it has been received and 
accepted), the original contents have been thor- 
oughly revised and mucn good and new matter 
has been incorporated. We have nothing but praise 
for Professor Maisch's work. It presents no weak 



point, even for the most severe critic. The book 
fully sustains the wide and well-earned reputa- 
tion of its popular author. In the special line of 
work of which it treats it is fully up to the most 
recent observations and investigations. After a 
careful perusal of the book, we do not hesitate to 
recommend Maisch's Manual of 'Organic Materia 
Medica as one of the best, if not the best work on 
the subject thus far published. Its usefulness 
cannot well be dispensed with, and students, drug- 
gists, pharmacists and physicians should all pos- 
sess a copy of such a valuable book. — Medical 
Neios, December 31, 1892. 



Edes' Therapeutics and Materia Medica. 



A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. By Bobert T. Edes, M. D., Jackson Professor of 
Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50 ; leather, $4.50. 

on having produced so good a one.— N. Y. Medical 
Journal, Feb. 18, 1888. 



It possesses all the essentials which we expect 
in a book of its kind, such as conciseness, clear- 
ness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated of. The clinical index at 
the end will be found very useful. We heartily 
commend the book and congratulate the author 



Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action. — Pharmaceutical Era, Jan. 1888. 



Bruce's Materia Medica and Therapeutics.— Fourth Edition. 

Materia Medica and Therapeutics. An Introduction to Bational Treat- 
ment. By J. Mitchell, Bruce, M. D., F. B. C. P., Physician and Lecturer on Materia 
Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 
12mo. volume of 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 30. 



The pharmacology and therapeutics of each drug 
are given with great fulness, and the indications for 
its rational employment in tbe practical treatment 
of disease are pointed out. The Materia Medica 
proper contains all that is necessary for a medical 
student to know at the present day. The third 



part of the book contains an outline of general 
therapeutics, each of the symptoms of the body 
being taken in turn, and the methods of treat- 
ment illustrated. A lengthy notice of a book so well 
known is unnecessary.— Med. Chronicle, May, 1891. 



HERMANN'S EXPERIMENTAL PHARMACOL- 
OGY. A Handoook of Methods for Determining 
the Physiological Action of Drugs. Translated, 
with the Author's permission, and with exten- 
sive additions, by R. M. Ssiith, M. D. 12mo., 
199 pages, with 32 illustrations. Cloth, $1.50. 



STILLE'S THERAPEUTICS AND MATERIA 
MEDICA. A Systematic Treatise on the Action 
| and Uses of Medicinal Agents, including their 
Description and History. Fourth edition, re- 
vised and enlarged. In two octavo volumes, con- 
taining 1936 pages. Cloth, $10.00 ; leather, $12.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



12 Therapeutics, flateria fledica — (Continued). 

A System of Practical Therapeutics 

BY AflERICAN AND FOREIGN AUTHORS. 



Edited by HOBART AHORY HARE, fl. D. 

Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. 

In a series of contributions by seventy-eight eminent authorities. In three large 
octavo volumes of 3544 pages, with 434 illustrations. Price, per volume : Cloth, $5.00 ; 
leather, $6.00 ; half Russia, $7.00. For sale by subscription only. Address the Publishers. 
Full prospectus free to any address on application. 



The various divisions have been elaborated by 
men selected in view of their special fitness. In 
every case there is to be found a clear and concise 
description of the disease under consideration, 
corresponding with the most recent and well- 
established views of the subject, embracing appo- 
site pictorial illustrations where these are neces- 
sary. In treating of the employment of remedies 
and therapeutical measures, the writers have 
been singularly happy in giving in a definite way 
the exact methods employed and the results ob- 
tained, both by themselves and others, so that one 
might venture with confidence to use remedies 
with which he was previously entirely unfamiliar. 
The practitioner could hardly desire a book on 
practical therapeutics which he could consult with 
more interest and profit.— The North American 
Practitioner, September, 1892. 

The scope of this work is beyond that of any 
previous one on the subject. The goal, after all, 



is the treatment of disease, and a work which con- 
tributes to its successful management is to be 
looked upon as of vast use to humanity. It can- 
not be denied that therapeutic resources, whether 
the treatment be confined to the mere administra- 
tion of drugs, or allowed its more extended appli- 
cation to the management of disease, have so 
greatly multiplied within the last few years as to 
render previous treatises of little value. Herein 
will be found the great value of f) are's encyclo- 
pedic work, which groups together within a single 
series of volumes the most modern methods 
known in the management of disease, and espe- 
cially deals with important subjects comprehen- 
sively, which could not be done in a more limited 
treatise. We cannot commend Hare's System 
of Practical Therapeutics too highly; it stands 
out first and foremost as a work to be consulted 
by authors, teachers, and physicians, throughout 
the world. — Buffalo Med. and Surg. Jour., Aug. 1892. 



Hare's Text-Book of Practical Therapeutics.— New (3d) Ed. 

A Text-Book of Practical Therapeutics ; With Especial Keference to 
the Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica 
in the Jefferson Medical College of Philadelphia ; Sec. of Convention for Revision of U. S. 
Pharmacopoeia of 1890. With special- chapters by Drs. G. E. de Schweinitz, Edward 
Martin, J. Howard Reeves and Barton C. Hirst. New (3d) and revised edition. 
In one octavo volume of 689 pages. Cloth, $3.75 ; leather, $4.75. Just Heady. 

We find here directions for the use of the drugs 
of the most recent introduction, and the very lat- 



est results obtained in the treatment of disease by 
these newer remedies. There is also a list of 
drugs arranged according to their physiological 
action, and a list of definitions of the terms used to 
designate classes of drugs. In a word, this book 
is a treatise on drugs and other remedial 
measures, with especial reference to their practi- 
cal uses; and also a treatise on diseases, with full 



directions for the most approved treatment. The 
book closes with a table of doses and an index of 
diseases and remedies. There are some books 
that the student and practitioner alike would do 
well to purchase; there are others they must 
have. To this latter class belong the text-books 
on practical therapeutics. Certainly none can be 
found either more practical or more complete than 
this.— The National Medical Review, February 2, 
1893. 



Brunton's Therapeutics and Materia Medica.— Third Ed. 

A Text-Book of Pharmacology, Therapeutics and Materia 
Medica; By T. Lauder Brtjnton, M. D., D. Sc, F.R. S., F.R.C.P., Lecturer on 
Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. Including 
the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Adapted to the U. S. Pharmacopoeia by Frances H. Williams' M. D., of Harvard Univ 
Med. School. Third edition. Octavo, 1305 pages, 230 ill us. Leather, $6.50. 

No words of praise are needed for this work, for made in various directions in the art of therapeu- 
it has already spoken for itself in former editions. 
It was by unanimous consent placed among the 
foremost books on the subject ever published in 
any language, and the better it is known and studied 
the more highly it is appreciated. The present 
edition contains much new matter, the insertion 
of which has been necessitated by the advances 



tics, and it now stands unrivalled in its thoroughly 
scientific presentation of the modes of drug action. 
No one who wishes to be fully up to the times in 
this science can afford to neglect the study of Dr. 
Brunton's work. The indexes are excellent, and 
add not a little to the practical value of the book. 
—Medical Record, May 25, 1889. 



Farquharson's Therapeutics and Materia Medica.— 4th Ed. 

A Guide to Therapeutics and Materia Medica. By Robert Far- 
qtjharson, M. D., F. R. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospi- 
tal Medical School, London. Fourth American, from' the fourth English edition. 
Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- 
fessor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chi- 
rurgical College of Philadelphia. In one handsome 12mo. vol. of 581 pp. Cloth, $2.50. 

copceias, as well as considering all non-official but 



It may correctly be regarded as the most modern 
ork of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 



a place in the British and United States Pharma- 



important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal, June, 1889. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine. 



13 



Flint's Practice of Medicine.— Sixth Edition. 

A Treatise on the Principles and Practice of Medicine. Designed 
for the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., 
Professor of the Principles and Practice of Medicine, and of Clinical Medicine in Belle- 
vue Hospital Medical College, N. Y. Sixth edition, thoroughly revised and rewritten 
by the Author, assisted by William H. Welch, M. D., Professor of Pathology, 
Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., Professor 
of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome octavo 
volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. 

No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 



in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art.— Cincinnati Medical News, Oct. 1886. 



Bristowe's Practice of Medicine.— Seventh Edition. 

A Treatise on the Science and Practice of Medicine. By John 
Syee, Bristowe, M. D., LL. D., F. E. S., Senior Physician to and Lecturer on Medicine 
at St. Thomas' Hospital, Londou. Seventh edition. In one large octavo volume of 1325 
pages. Cloth, $6.50 ; leather, $7.50. 



Hartshorne's Essentials of Practice.— Fifth Edition. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. By Henry Haetshoene, M. D., LL. D., lately Professor 
of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and 
rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75 ; half leather, $3. 

a better average of actual practical treatment than 
this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen 



Within the compass of 600 pages it treats of the 
nistory of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 



tials are most valuable in affording the means to 
see at a glance the whole literature of any disease, 
and the most valuable treatment. — Chicago Medical 
Journal and Examiner, April, 1882. 



Reynolds' System of Medicine. 

A System of Medicine. By J. Rtjsseee Keynolds, M. D., Professor of the 
Principles and Practice of Medicine in University College, London. With notes and 
additions by Henry Haetshorne, A. M., M. D., late Professor of Hygiene in the Uni- 
versity of Pennsylvania. In three large and handsome octavo volumes, containing 3056 
double-columned pages, with 317 illustrations. Price per volume, cloth, $5.00; sheep, 
$6.00; half Kussia, raised bands, $6.50. Per set, cloth, $15.00 ; leather, $18.00 ; half 
Russia, $19.50. Sold only by subscription. 



Cohen's Applied Therapeutics. 

A Handbook of Applied Therapeutics. Being a Study of Principles 
Applicable and an Exposition of Methods Employed in the Management of the Sick. 
By Solomon Sous Cohen, M. IX, Professor of Clinical Medicine and Applied Thera- 
peutics in the Philadelphia Polyclinic. In one large 12mo. vol., with illus. Preparing. 



WATSON'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF PHYSIC. From the fifth 
English edition. Edited with additions, and 190 
illustrations, by Henry Haetshobne, A.M., M. D., 
late Professor of Hygiene in the University of 
Pennsylvania. In two large octavo volumes of 
1840 pages. Cloth, $9.00; leather, 311.00. 

FLINT ON PHTHISIS: ITS MORBID ANAT- 
OMY, ETIOLOGY, SYMPTOMATIC EVENTS 
AND COMPLICATIONS, FATALITY AND 
PROGNOSIS, TREATMENT AND PHYSICAL 
DIAGNOSIS; in a series of Clinical Studies. In 
one octavo volume of 442 pages. Cloth, $3.50. 

FLINT'S PRACTICAL TREATISE ON THE 
DIAGNOSIS, PATHOLOGY AND TREATMENT 



OF DISEASES OF THE HEART. Second re- 
vised and enlarged edition. In one octavo vol- 
ume of 550 pages, with a plate. Cloth, $4. 

FLINT'S ESSAYS ON CONSERVATIVE MEDI- 
CINE AND KINDRED TOPICS. In one very 
handsome royal 12mo. volume of 210 pages. 
Cloth, $1.38. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K. C O. In one 8vo. vol. of 354 pp. Cloth, $2.25. 

LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 

LA ROCHE ON YELLOW FEVER, in its Histori- 
cal, Pathological, Etiological and Therapeutical 
Relations. Two octavo vols., 1468 pp. Cloth, $7.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



14 Prac. of fledicine, Treatment, Digestive Syst. 



Lyman's Practice of Medicine. 

The Principles and Practice of Medicine. For the Use of Medical 
Students and Practitioners. By Henry M. Lyman, M. D., Professor of the Principles 
and Practice of Medicine, Push Medical College, Chicago. In one very handsome octavo 
volume of 925 pages, with 170 illustrations. Cloth, $4.75 ; leather, $5.75. 

This is an excellent treatise on the practice of What the student should be taught is the one 

most approved method of treatment. We have 
spoken of the work as one for the student, and 
this because the author occupies so prominent a 
position as a teacher, but we would not be under- 
stood that it is adapted only for students. There 
is many a practitioner of ten years' or more stand- 
ing, who has been unable to follow the constant 
advances made in medical science, to whom this 
work will be of great use. He will find here each 
subject presented in its latest aspect, and only 
such theories mentioned as have been generally 
accepted by the highest authorities. The practi- 



medicine, written by one who is not only familiar 
with his subject, but who has also learned through 
practical experience in teaching, what are the 
needs of the student, and how to present the facts 
to his mind in the most readily assimilable form. 
Although the book contains over nine hundred 

Eages, there has been no space wasted by useless 
istorical essays, prolonged discussions on de- 
batable topics, or "padding" of any kind. Each 
subject is taken up in order, treated clearly but 
briefly, and dismissed when all has been said that 
need be said in order to give the reader a clean- 
cut picture of the disease under discussion. The 
reader is not confused by having presented to him 
a variety of different methods of treatment, among 
Which he is left to choose the one most easy of exe- 
cution, but the author describes the one which is, 
in his judgment, the best. This is as it should be. 



cal and busy man who wants to ascertain in a 
short time all the necessary facts concerning the 
pathology or treatment of any disease, will find 
here a safe and convenient guide.— Medical Rec- 
ord, October 22, 1892. 



The Year-Book of Treatment lor 1893. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine and Surgery. In one 12mo.vol. of 501 pages. Cloth, $1.50. 

#\ For special commutations with periodicals see pages 1 and 2. 
The Year-Book of Treatment for 1893 easily 
holds its advanced place among the many annuals 
and abstracts forming so marked a feature of 
modern medical literature. Its pages give a criti- 
cal and well-arranged review of the best that the 



year has brought forth in all departments of ther- 



apeutics. Among so much that is excellent one 
can scarcely choose. Commendable features are 
the Summary of Therapeutics and the Selected 
List of New Books. There is as usual a good 
index.— The Medical News, May 20, 1893. 



The Year-Books of Treatment for 1891 and 1392. 

12mos., 485 pages. Cloth, $1.50 each. 



The Year-Books of Treatment for 1886 and 1887. 

Similar to above. 12mo., 320-341 pages. Cloth, $1.25 each. 
For Sale by Subscription Only, 

A System of Practical Medicine. 

BY AMERICAN A TJTHORS. 
Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. 



* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 



lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome of 
American brains, and is marked throughout by 
much of the sturdy independence of thought and 
originality that is a national characteristic. Yet no- 
where is there lack of study of the most advanced 
views of the day.— N. C. Med. Jowr. t Sept. 1886. 



Habershon on the Abdomen. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. By 
S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- 
tice of Medicine at Guy's Hospital, London. Second American from third enlarged and 
revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. 



This valuable treatise on diseases of the stomach 
and abdomen will be found a cyclopaedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 



rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
—New York Medical Journal, April, 1879. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine, Diagnosis, Heart. 15 



Whitla's Dictionary of Treatment. 

A Dictionary of Treatment ; or Therapeutic Index, including 
Medical and Surgical Therapeutics. By William Whitla, M. D., Professor 
of Materia Medica and Therapeutics in the Queen's College, Belfast. Revised and adapted 
to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00. 

tical scientific therapeutist, who has carefully 
studied diseases and disorders at the bed-side and 
in the consulting-room, and has earnestly ad- 
dressed himself to the cure and relief of his 
patients. Dr. Whitla is to be congratulated upon 
the thoroughness with which he has realized his 
idea. — The Glasgow Medical Journal, April, 1892. 

This is a book for the busy general practitioner. 
It is more than a therapeutic index presenting as 
it does clinical therapeutics in its broadest aspect. 
The names of diseases and of prominent condi- 
tions and symptoms are arranged alphabetically, 
while under each title is presented a concise yet 
thorough consideration of the best and generally 
accepted methods of treatment, precedence gen- 
erally being given to those the efficacy of which 
has been demonstrated in the experience of the 
author. No department of medicine has been 
ignored. An index of nineteen pages gives com- 
pleteness to the work, and renders reference easy. 
This book will be of great assistance to the medi- 
cal practitioner. — The Medical News, April 16, 1892. 



Dr. "Whitla has, we think, been fortunate in the 
selection of a title for his latest work. We have 
already dictionaries of medicine and dictionaries 
of surgery; he now provides us with a dictionary 
of treatment. And reference to the volume shows 
that it really is what it professes to be. The sev- 
eral diseased conditions are arranged in alphabet- 
ical order, and the methods— medical, surgical, 
dietetic, and climatic— by which they may be met, 
considered. On every page we find clear and de- 
tailed directions for treatment supported by the 
author's personal authority and experience, whilst 
therecommendations of other com petentobservers 
are also critically examined. The book abounds 
with useful, practical hints and suggestions, and 
the younger practitioner will find in it exactly the 
help he so often needs in the treatment both of 
those who are ill, and those who are ailing. At the 
same time the most experienced members of the 
profession may usefully consult its pages for the 
purpose of learning what is really trustworthy in 
the later therapeutic developments. The Diction- 
ary is, in short, the recorded experience of a prac- 



Fothergill's Handbook of Treatment.— Tliird Edition. 

The Practitioner's Handbook of Treatment ; Or, The Principles of 
Therapeutics. By J. Milnee, Fothergill, M. D., Edin., M.E. C. P., Lond., Physician 
to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. 
volume of 661 pages. Cloth, $3.75 ; leather, $4.75. 

This is a wonderful book. If there be such a 
thing as "medicine made easy," this is the work to 
accomplish this result.— Va. Med. Month., June,'87. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 
a great convenience to many thoughtful but busy 



physicians. The practical value of the volume is 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition.— N. Y. Med. Jour., June 11,'87. 
We do not know a more readable, practical and 
useful work on the treatment of disease.— Pacific 
Medical and Surgical Journal, October, 1887. 



Flint on Auscultation and Percussion.— Fifth Edition. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis 
of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D.> 
LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- 
cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer 
on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- 
some royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75. 

This little book through its various editions has 
probably done more to advance the science of 
physical exploration of the chest than any other 



dissertation upon the subject, and now in its fifth 
edition it is as near perfect as it can be. The 
rapidity with which previous editions were sold 
shows how the profession appreciated the thor- 



oughness of Prof. Flint's investigations. For stu- 
dents it is excellent. Its value is shown both in 



the arrangement of the material and in the clear, 
concise style of expression. For the practitioner 
It is a ready manual for reference.— North Ameri- 
can Practitioner, January, 1891. 



Musser's Medical Diagnosis.— Preparing. 

A Practical Treatise on Medical Diagnosis. For the Use of Students 
and Practitioners. By John H. Musses,, M. D., Assistant Professor of Clinical Medicine, 
University of Pennsylvania, Philadelphia. In one octavo vol. of about 650 pp. Preparing. 

Broadbent on the Pulse. 

The Pulse. By W. H. Broadbent, M. D., F. R C. P., Physician to and Lecturer 
on Medicine at St. Mary's Hospital, London. In one 12mo. volume of 312 
Cloth, $1.75. See Series of Clinical Manuals, page 30. 



TANNER'S MANUAL OF CLINICAL MEDICINE 
AND PHYSICAL DIAGNOSIS. Third American 
from the second London edition. Revised and 
enlarged by Tilbury Fox, M.D. In one 12mo, 
volume of 362 pp. with illus. Cloth, $1.50. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, 81.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth. $2.50. 

FLINT'S PRACTICAL TREATISE ON THE 
PHYSICAL EXPLORATION OF THE CHEST 



AND THE DIAGNOSIS OF DISEASES AF- 
FECTING THE RESPIRATORY ORGANS^ 
Second and revised edition. In one handsome 
octavo volume of 591 pages. Cloth, $4.50. 

STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide ta 
the Investigation of Disease. In one handsome 
l2mo. volume of 127 pages. Cloth, $1.25. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

HOLLAND'S MEDICAL NOTES AND REFLEO- 
| TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



16 Practice, Electricity, Cholera, Food, Hygiene. 
Bartfaolow on Electricity in Medicine and Surgery — 3d Ed. 

Medical Electricity. A Practical Treatise on the A pplications of Electricity 
to Medicine and Surgery. By Kobee/ts Barthoi-ow, A. M., M. L\, LL. D., Emeritus Pro- 
fessor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila- 
delphia, etc. Third edition. In one octavo volume of 308 pp., with 110 illus. Cloth, $2.50. 

Professor Bartholow's practical treatise on the 
application of electricity to medicine and surgery, 
having reached a third edition, scarcely requires 



detailed notice. Originally intended for students 
and practitioners, it starts by assuming an " entire 
unacquaintance with the elements of the subject." 
The work appears to be fitted by its extreme 
lucidity for the use of busy practitioners who re- 
quire a guide in practical electro-therapeutics. — 
London Lancet, January 14, 1888. 
The fact that this work has reached its third edi- 



tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity, demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
The matter added to the present edition embraces 
the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical News, May 14, 1887. 



Bartholow on Cholera — Just Ready. 

Cholera: Its Causes, Symptoms, Pathology and Treatment. By 

Eoberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General 
Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. 
volume of 127 pages, with 9 illustrations. Cloth, $1.25. 



The most scientific work on cholera extant. 
Broad yet comprehensive, concise but explicit, it 
treats the subject in a way to invite bat little criti- 
cism. The most valuable chapter is the one on 
treatment, which, considering the author's thera- 
peutical experience, and the great improvement 
made in practice, is indeed, a contribution to 
medical literature worthy of more than passing 
notice — The Medical Fortnightly, July 15, 1893. 

The author has sought to make a practical book 
in the smallest compass. The symptoms and 



pathology of the disease are described separ- 
ately in a brief and comprehensive manner. The 
final chapter, on the treatment of cholera, gives 
the prophylactic measures, including quarantine 
and the latest therapeutical methods in vogue in 
India, Europe and America The volume is writ- 
ten in the author's usual pleasant style, and will 
satisfy the desire of any one that wishes to obtain 
the most recent information on the subject. — The 
New York Medical Journal, July 29, 1893. 



Yeo on Food in Health and Disease. 

Food in Health and Disease. By I. Burney Yeo, M. D., F. E. C. P., 

Professor of Clinical Therapeutics in King's College, London. In one 12mo. volume of 
590 pages. Cloth, $2,00. See Series of Clinical Manuals, page 30. 



Dr. Yeo supplies in a compact form nearly all that 
the practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered 
together from ail quarters an immense amount of 
useful information within a comparatively small 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo. — British Medical 
Journal, Feb. 8, 1890. 



Yeo's Medical Treatment— Just Ready. 

A Manual of Medical Treatment or Clinical Therapeutics. By 

I. Burney Yeo, M. L\, F. R C. P., Prof, of Clinical Therapeutics in King's Coll., London. 
In two 12mo. volumes containing 1275 pages, with illustrations. Cloth, $5.50. 

In this work disease is studied from the standpoint of treatment, the rational indi- 
cations for therapeutics being reached through an explanation of the causation and 
phenomena of disease, and the properties and mode of action of the agencies available for 
exerting favorable influence. The work is rich in selections of formulae used by well- 
known physicians. 



Richardson's Preventive Medicine. 

Preventive Medicine. By B. W. Bichardson, M. D., LL. D., F. E. S., Fel- 
low of the Boyal Coll. of Phys., London. In one 8vo. vol. of 729 pp. Cloth, $4; leather, $5. 

scholarly ; the discussion of the question of disease 
is comprehensive, masterly and fully abreast with 
the latest and best knowledge on the subject, and 



There is perhaps no similar work written for 
the general public that contains such a complete, 
reliable and instructive collection of data upon 
the diseases common to the race, their origins, 
causes, and the measures for their prevention. 
The descriptions of diseases are clear, chaste and 



the preventive measures advised are accurate, 
explicit and reliable. — TheAmerican Journal of the 
Medical Sciences, April, 1884. 



SCHREIBER'S MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EX- 
ERCISE. Translated by Walter Mendelson, 
M. D., of New York. In one 8vo. volume of 274 
pp., with 117 engravings. 

STILLE ON CHOLERA: Its Origin, History, 
Causation, Symptoms, Lesions, Prevention and 
Treatment. In one handsome 12mo. volume of 
163 pages, with a chart. Cloth, $1.25. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 

• ; M.D. 1 vol. 8vo., pp. 603. Cloth, 82.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Throat, Nose, Lungs, Hind, Nerves, 



17 



Seiler on the Throat and Nose.— New (4th) Ed. Just Ready. 

A Handbook of Diagnosis and Treatment of Diseases of the 
Throat, Nose and Naso-Pharynx. By Carl Seiler, M. D., Lecturer on 
Laryngoscopy in the University of Pennsylvania. New (4th) edition. In one handsome 
12mo. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. 

gains rather than loses by that brevity. Another 



Though the work aims at brevity and concise- 
ness, and though much— in fact almost all— that is 
theoretical has been omitted, yet thereby the work 
has gained in practical value and intej est. Com- 
plete in an exhaustive sense it certainly is not; 
and yet in a more practical sense, and particularly 
from the therapeutic standpoint, its lack of com- 
pleteness is of the greatest value, since it casts 
aside the chaff and preserves the wheat, presenting 
it, moreover, in well-arranged, concise and, what 
is still more unusual, exceedingly readable form. 
Certain new features appear in this edition, and of 
these the best is the chapter on intra nasal neo- 
plasms, which, though brief, is yet sufficient, and 



new chapter is on influenza and "American Grippe." 
The size of the volume is most convenient and 
the book-making excellent.— The New York Medi- 
cal Journal, May 13, 1893. 

The fourth edition of Seiler's admirable work 
should be warmly received by both practitioners 
and students as it well deserves. There is no 
special work of its size, on diseases of the throat 
and nose that contains more information, yet it is 
arranged in such a concise, compact form that it 
makes an exceedingly handy reference book for 
the busy practitioner as well as a good text-book 
for the student.— Pacific Medical Record, May, 1893. 



Browne on the Throat and Nose. 

The Throat and Nose and Their Diseases. By Lennox Browne, 
F. E. C. S., E., Senior Physician to the Central . London Throat and Ear Hospital. 
Fourth and enlarged edition. In one imperial octavo volume of about 750 pages, 
120 illustrations in color, and 235 engravings on wood. Cloth, $6.50. Just ready. 

A notice of the previous edition is appended. 



with 



The beautiful and typical colored plates form 
a valuable and instructive atlas, the equal of which 
is not to be found in any modern work, treating 
of these subjects. Mr. Lennox Browne is to be 
congratulated on having produced the best prac- 



tical text-book on diseases of the throat and nose 
extant. We are glad to learn that it is being 
translated into French and German. — The Provin- 
cial Medical Journal, August 1, 1890. 



Tuke on the Influence o! the Mind on the Body. 

Illustrations of the Influence of the Mind upon the Body in 
Health and Disease. Designed to elucidate the Action of the Imagination. By 
Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, 
etc. New edition. Thoroughly revised and rewritten. In one 8 vo. volume o*f 467 pages, 
with 2 colored plates. Cloth, $3.00. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6, 1884. 



Clouston on Mental Diseases. 

Clinical Lectures on Mental Diseases. By Thomas S. Clouston, 
M. D., Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- 
dix, containing an Abstract of the Statutes of the United States arid of the Several 
States and Territories relating to the Custody of the Insane. By Charles F. Folsom, 
M. D., Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo 
volume of 541 pages, with eight lithographic plates, four of which are colored. Cloth, $4. 
JlilPDr. Folsom's Abstract also separate, in one 8vo. vol. of 108 pages. Cloth, $1.50. 
The descriptions of the diseases and cases are and descriptions given as to the practical man- 
simple and practical, but true; and one sees as he agement and care of the cases. We can heartily 
reads that they are given by one perfectly familiar recommend it to the student and busy general 
from daily observation with the cases and diseases practitioner. Dr. Folsom's work greatly increases 
he is speaking of. One feature of the book which the value of Dr. Clouston's book for the American 
commends it highly, and which is not to be found practitioner. — Archives of Medicine, June, 1884. 
in any other work on mental diseases, is the hints 



Playfair on Nerve Prostration and Hysteria. 

The Systematic Treatment of Nerve Prostration and Hysteria. 

By W. S. Playfaik, M. D., F. E. C. P. In one 12mo. volume of 97 pages. Cloth, $1.00. 



BROWNE ON KOCH'S REMEDY IN RELATION 
TO THROAT CONSUMPTION. In one octavo 
volume of 121 pages, with 45 illustrations, 4 of 
which are colored, and 17 charts, Cloth, $1.50. 

FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 



valence in various Countries. Second and revised 
edition. In one 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



18 Nervous and flental Diseases, Histology. 
Gray on Nervous and Mental Diseases. 

A Practical Treatise on Nervous and Mental Diseases. By 

Landon Carter Gray, M. D., Professor of Diseases of the Mind and Nervous System 
in the New York Polyclinic. In one very handsome octavo volume of 681 pages, with 
168 illustrations. Cloth, $4.50; leather, $5.50. 

A book that will be welcomed by the many who 
desire a modern text-book on nervous diseases 
that is comprehensive and practical, and especial- 
ly full in the details of the treatment of these 
affections that are so often matters of perplexity 
to the general practitioner. It will be found, on 
this account, to meet the wants of a large number 
perhaps better than would another equally meri 
torious text-book less full in this regard. Dr. Gray 
states in his preface, and it is evident to anyone 
perusing the work, that "especial care has been 
taken to make the therapeudcal suggestions suf- 
ficiently detailed and prt cise to cover the varying 
stages, symptoms and complications of disease, as 
well as to follow the important indications afford- 
ed by differential diagnosis," and that "only that 
knowledge has been admitted to these;; pages 
which has stood the test of experience." Its style 
is clear and very readable, and the illustrations are 
numerous and excellent. A glossary of special 



terms is appended which will be found useful by 
the student. While it is intended as a text-book, 
not assuming any special knowledge on the part 
of its readers, the volume is full of valuable orig- 
inal matter that renders it a desirable addition to 
the library of the specialist in nervous and mental 
diseases.— American Jour, of Mental Sci. Feb., 1893. 
A highly successful effort to condense into a 
volume of reasonable size a practical knowledge 
of nervous and mental diseases. It is a book 
which the neurologist can consult with interest 
and advantage, and one which will be found par- 
ticularly useful to the student and general prac- 
titioner. The large space which throughout the 
work has been given to the discussion of sympto- 
matology and treatment will serve to make it 
popular, especially with busy workers. Dr. Gray's 
book will long hold its place as a standard treatise. 
— The Medical News, April 15, 1893. 



Ross on Diseases of the Nervous System. 

A Handbook on Diseases of the Nervous System. By James 
Ross, M. D., F. R. C. P., LL.D., Senior Assistant Physician to the Manchester Royal 
Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50 ; leather, $5.50. 



This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh MedicalJournal, Jan. 1887. 



Hamilton on Nervous Diseases.— Second Edition. 

Nervous Diseases ; Their Description and Treatment. By Allen McLane 
Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, 
Blackwell's Island, N. Y. Second edition, thoroughly revised and rewritten. In one 
octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. 

When the first edition of this good book appeared characterized this book as the best of its kind in 
we gave it our emphatic endorsement, and the any language, which is a handsome endorsement 
present edition enhances our appreciation of the from an exalted source. The improvements in the 
book and its author as a safe guide to students of new edition, and the additions to it, will justify its 
clinical neurology. One of the best and most purchase even by those who possess the old. — 
critical of English neurological journals, Brain, has Alienist and Neurologist, April, 1882. 



Savage on Insanity and Allied Neuroses. 

Insanity and Allied. Neuroses, Practical and Clinical. By George 
H. Savage, M. D., Lecturer on Mental Diseases at Guy's Hospital, London. In one 
12mo. vol. of 551 pp., with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, .p. 30. 

Klein's Histology.— Fourth Edition. 

Elements of Histology. By E. Klein, M. D., F. E. S., Joint Lecturer on 
General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, 
London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp 
cloth, $1.75. See Students' Series of Manuals, page 30. 

which it is written, the 



The large number of editions through which 
Dr. Klein's little handbook of histology has run 
since its first appearance in 1883 is ample evidence 
that it is appreciated by the medical student and 
that it supplies a definite want. The clear and 



concise manner m wnicn it is 
absence of debatable matter, of conflicting views, 
added to the convenient size of the book and its 
moderate price, will account for its undoubted 
success. — Medical Chronicle, Feb., 1890. 



Schafer's Histology.— Third Edition. 

The Essentials of Histology. By Edward A. Schafer, F. E. S., Jodrell 
Professor of Physiology in University College, London. JSew (third) edition. In one 
octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very 
handsome octavo volume. 

JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 



American Edition. In one handsome octavo 
volume of 340 pages. Cloth, $3.25. 
PEPPER'S SURGICAL PATHOLOGY. In one 
pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Pathology, Histology, Bacteriology. 



19 



Gibbes' Practical Pathology and Morbid Histology. 

Practical Pathology and Morbid Histology. By Heneage Gibbes, 
M. D„ Professor of Pathology in the University of Michigan, Medical Department. In 
one very handsome 8vo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, |2.75. 



This is, in part, an expansion of the little work 
published by the author some years ago, and his 
acknowledged skill as a practical microscopist will 
give weight to his instructions. Indeed, m ful- 
ness of directions as to the modes of investigating 
morbid tissues the book leaves little to be desired. 



The work is throughout profusely illustrated with 
reproductions of micro-photographs. We may 
say that the practical histologist will gain much 
useful information from the book.— The London 
Lancet, January 23, 1892. 



Abbott's Bacteriology. 

The Principles of Bacteriology : a Practical Manual for Students and 
Physicians. By A. C. Abbott, M. D., First Assistant, Laboratory of Hygiene, University 
of Pennsylvania, Philadelphia. In one 12mo. vol. of 259 pp., with 32 illus. Cloth, $2.00. 



To a person desiring to learn the technique of 
bacteriological work, we cannot recommend any 
work which will be more suitable than the one 
before us The fault which can be found with 
most of the works we have met with on this sub- 
ject, is that they are too extended for the use of a 
student or practitioner beginning the subject and 
yet are not sufficiently large to allow of an ex- 
haustive treatment. Dr. Abbott has shown great 



judgment in the selection and arrangement of 
his material. The student who follows it closely 
will be in a condition to carry forward the work 
forhimself. Medical practitionersgenerallycould 
read the work with profit, especially the chapters 
on sterilization and disinfection, and those on 
tuberculosis and diphtheria in the second part. — 
The Canadian Practitioner, Nov. 1, 1892. 



Senn's Surgical Bacteriology.— Second Edition. 

Surgical Bacteriology. By Nicholas Senn, M. D., Ph. D., Professor of 
Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome 
octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. 



The book is really a systematic collection in the 
most concise form of such results as are published 
in current medical literature by the ablest workers 
in this field of surgical progress ; and to these are 
added the author's own views and the results of 
his clinical experience and original investigations. 
The book is valuable to the student, but its chief 
value lies in the fact that such a compilation 



makes it possible for the busy practitioner, whose 
time for reading is limited and whose sources of 
information are often few, to become conversant 
with the most modern and advanced ideas in sur- 
gical pathology, which have "laid the foundation 
for the wonderful achievements of modern sur- 
gery." — Annals of Surgery, March, 1892. 



Green's Pathology and Morbid Anatomy.— Seventh Edition. 

Pathology and Morfoid Anatomy. By T. Henry Green, M. D., Lecturer 
on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 
Sixth American from the seventh revised English edition. Octavo, 539 pages, with 167 
engravings. Cloth, $2.75. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances of 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its favor.— Cincinnati Medical News, Oct. 
1889. 



Payne's General Pathology. 



A Manual of General Pathology. Designed as an Introduction to the 
Practice of Medicine. By Joseph F. Payne, M. D., F. K. C. P., Senior Assistant Physi- 
cian and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 
524 pages, with 152 illustrations and a colored plate. Cloth, $3,50. 

cal factors in those diseases now with reasonable 
certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth the price of the 
book, several times over, to every student of 
pathology.— St. Louis Med. and Surg. Jour., Jan. '89. 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



Coats' Treatise on Pathology. 



A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- 
gist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 
pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 



Medical students as well as physicians, who 
desire a work^ for study or reference, that treats 
the subjects fn the various departments in a very 
thorough manner, but without prolixity, will cer- 
tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 
recent discoveries, exhibits, in an interesting 



manner, the changes from a normal condition 
effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions. — Cincinnati Medical News, Oct. 1883. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



20 



Surgery. 



Roberts' Modern Surgery. 

The Principles and Practice of Modern Surgery. For the use of 

Students and Practitioners of Medicine and Surgery. By John B. Boberts, M. D., Pro- 
fessor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Princi- 
ples and Practice of Surgery in the Woman's Medical College of Pennsylvania. Lecturer 
in Anatomy in the University of Pennsylvania. In one very handsome octavo volume 
of 780 pages, with 501 illustrations. Cloth, $4.50; leather, $5.50. 



This work is a very comprehensive manual upon 
general surgery, and will doubtless meet with a 
favorable reception by the profession. It ha-j a 
thoroughly practical character, the subjects are 
treated with rare judgment, its conclusions are in 
accord witn those of the leading practitioners of 
the art, and its literature is fully up to all the ad- 



vanced doctrines and methods of practice of the 
present day. Its general arrangement follows 
this rule, and the author in his desire to be con- 
cise and practical is at times almost dogmatic, but 
this is entirely excusable considering the admira- 
ble manner in which he has thus increased the 
usefulness of his work.— Med. Bee., Jan. 17, 1891. 



Ashhurst's Surgery.— Fifth Edition. 

The Principles and Practice of Surgery. By John Ashhurst, 
Jr., M. D., Barton Professor of Surgery and Clinical Surgery in the Univ. of Penn., Sur- 
geon to the Penn. Hosp., Philadelphia. Fifth edition, enlarged and thoroughly revised. 
In one octavo volume of 1144 pages, with 642 illus. Cloth, $6.00 ; leather, $7.00. 

peat that commendation. The student, we believe, 



A complete and most excellent work on surgery. 
It is only necessary to examine it to see at once 
its excellence and rea,l merit either as text-book 
for the student or a guide for the general practi- 
tioner. It fully considers in detail every surgical 
injury and disease to which the body is liable, and 
every advance in surgery worth noting is to be 
found in its proper place. It is unquestionably the 
best and most complete single volume on surgery, 
in the English language, and cannot but receive 
that continued appreciation which its merits justly 
demand. — Southern Practitioner, Feb. 1890. 

In reviewing a previous edition we highly com- 
mended the work of Ashhurst to the student and 
practitioner as a text- book. We can heartily re- 



could not get a better book for obtaining a com- 
prehensive knowledge of surgery. The latest 
advances are referred to with sufficient clearness 
to stimulate to further study, and the teaching of 
the book is eminently conservative, but always 
judicious. As usual Dr. Ashhurst has included 
many valuable statistical tables, which have been 
revised up to date of preparation. No better 
single volume on surgery ran be found in the 
English language, and they are quite numerous. 
We commend it to our readers as a resume of the 
best modern methods in general and of American 
practice in particular. — The New Orleans Medical 
and Surgical Journal, Sept. 1890. 



Druitt's Modern Surgery.— Twelfth Edition. 

Manual of Modern Surgery. By Kobert Druitt, M. E. C. S. Twelfth 
edition, thoroughly revised by Stanley Boyd, M. B., B. S., F. E. C. S. In one 8vo. 
volume of 965 pages, with 373 illustrations. Cloth, $4.00; leather, $5.00. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 



appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times.— Cincinnati Medical 
News, September, 1887. 



Gross' System of Surgery.— Sixth Edition. 

A System of Surgery. By Samuel D. Gross, M. D., LL. D., Emeritus 
Professor of Surgery in the Jefferson Medical College of Philadelphia. Sixth edition. 
In two large imperial octavo volumes containing 2382 pages, illustrated with 1623 
engravings. Leather, raised bands, $15.00 ; half Kussia, $16.00. 



Young's Orthopaedic Surgery.— In Press. 

A Manual of Orthopaedic Surgery, for Students and Practi- 
tioners. By James K. Young, M. D., Instructor in Orthopaedic Surgery, University of 
Pennsylvania, Philadelphia. In one 12mo. vol. of about 400 pp., fully illustrated. 

Butlin on the Tongue. 

Diseases of the Tongue. By Henry T. Butlin, F. B. C. S., Assistant 
Surgeon to St. Bartholomew's Hospital, Londoc In one 12mo. volume of 456 pages, 
with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, p. 30. 

Gould's Surgical Diagnosis. 

Elements of Surgical Diagnosis. By A. Pearce Gould, M. S., M. K, 
F. R. C. S., Assistant Surgeon to Middlesex Hospital, London. In one pocket-size 12mo. 
volume of 589 pages. Cloth, $2.00. See Students' Series of Manuals, page 30. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 

GANT'S STUDENT'S SURGERY. By Frederick 
James Gant, F. R. C. S. Square octavo, 848 pages, 
159 engravings. Cloth, §3.75. 



MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American edition. In one large 8vo. 
vol. of 682 pp., with 364 illustrations. Cloth, §3.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh ed. In one 
8vo. vol. of 638 pages, with 340 illus. Cloth, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Surgery — (Continued). 



21 



Erichsen's Science and Art of Surgery.— Eighth Edition. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, 
Diseases and Operations. By John E. Erichsen, F. E. S., F. E. C.S., Professor of Sur- 
gery in University College, London, etc. From the eighth and enlarged English edition. 
In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. 

of the former edition has been dropped and no 
discovery, device or improvement which has 
marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
— Louisville Medical News, Feb. 14, 1885. 



For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 
through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 



Bryant's Practice of Surgery.— Fourth Edition. 

The Practice of Surgery. By Thomas Bryant, F. E. C. S., Surgeon and 
Lecturer on Surgery at Guy's Hospital, London. Fourth American from the fourth and 
revised English edition. In one large and very handsome imperial octavo volume of 1040 
pages, with 727 illustrations. Cloth, $6.50 ; leather, $7.50. 

place the work among the highest order of text- 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 



books for the medical student. Almost every 
topic in surgery is presented in such a form as to 
enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical.-C7uctt(70.Me(i. Jour, and Examiner, Apr. '86. 



Wharton's Minor Surgery and Bandaging.— 2d Ed. Just Ready. 

Minor Surgery and Bandaging. By Henry E. Wharton, M. D., 
Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 
529 pages, with 416 engravings, many being photographic. Cloth, $3.00. 
A notice of the previous edition is appended. 



This new work must take a first rank as soon as 
examined. Bandaging is well described by words, 
and the methods are illustrated by photographic 
drawings, so as to make plain each step taken in 
the application of bandages of various kinds to dif- 
ferent parts of the body and extremities— including 
the head. The various operations are likewise de- 
scribed and illustrated, so that it would seem easy 
for the tyro to do the gravest amputation. The va- 



rious established operations are described in detail. 
Hence this work becomes a most valuable compan- 
ion-book to any of the more pretentious treatises 
on surgery, where simply the general advice is 
given to bandage, amputate, intubate, operate, etc. 
For the student and young surgeon, it is a very 
valuable instruction book from which to learn how 
to do what may be advised, in general terms, to be 
done. — Virginia Medical Monthly, October 1891. 



Treves' Operative Surgery.— Two Volumes. 

A Manual of Operative Surgery. By Frederick Treves, F.E. C. S., 
Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes 

Complete work, cloth, $9.00; leather, $11.00. 
not fail to be of the greatest use both to practical 
surgeons and to those general practitioners who, 
owing to their isolation or to other circumstances, 
are forced to do much of their own operative work. 
We feel called upon to recommend the book so 



containing 1550 pages, with 422 engravings. 
Mr. Treves in this admirable manual of opera- 
tive surgery has in each instance practically 
assumed that operation has been decided upon 
and has then proceeded to give the various opera- 
tive methods which may be employed, with a 
criticism of their comparative value and a detailed 
and careful description of each particular stage 
of their performance. Especial attention has been 
paid to the preparatory treatment of the patient 
and to the details of the after treatment of the 
case, and this is one of the most distinctive among 
the many excellent features of the book. We have 
no hesitation in declaring it the best work on the 
subject in the English language, and indeed, in 
many respects, the best in any language. It can- 



strongly for the excellent judgment displayed in 
the arduous task of selecting from among the 
thousands of varying procedures those most 
worthy of description ; for the way in which the 
still more difficult task of choosing among the 
best of those has been accomplished; and for the 
simple, clear, straightforward manner in which 
th'e information thus gathered from all surgical 
literature has been conveyed to the reader. — 
Annals of Surgery, March, 1892. 



In 



one 



Treves' Student's Handbook of Surgical Operations. 

square 12mo. volume of 508 pages, with 91 illustrations. Cloth, $2.50. 

A Manual of Surgery. In Treatises by Various Authors, edited by Fred- 
erick Treves, F. E. C. S. In three 12mo. volumes, containing 1866 pages, with 213 
engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. 



We have here the opinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, 
with 60 illus. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. 

Holmes' System of Surgery.— American Edition. 

A System of Surgery; Theoretical and Practical. By Various 
Authors. Edited by Timothy Holmes, M. A. American edition, revised and re- 
edited by John H. Packard, M.D. Three large octavo vols., 3137 pp., 979 illus. on wood 
and 13 lith. plates. Per set, cloth, $18 ; leather, $21. Subscription only. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



22 Surgery — (Continued), Fractures, Dislocations. 
Smith's Operative Surgery.— Revised Edition. 

The Principles and Practice of Operative Surgery. By Stephen 
Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. 
Second and thoroughly revised edition. In one very handsome octavo volume of 892 
pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00. 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. The book is a compendium 
for the modern surgeon. The present edition is 
much enlarged, and the text has been thoroughly 
revised, so as to give the most improved methods 
in aseptic surgery, and the latest instruments 
known for operative work. It can be truly said that 
as a handbook for the student, a companion for the 



surgeon, and even as a book of reference for the 
physician not especially engaged in the practice 
of surgery, this volume will long hold a most 
conspicuous place, and seldom will its readers, no 
matter how unusual the subject, consult its pages 
in vain. Its compact form, excellent print, num- 
erous illustrations, and especially its decidedly 
practical character, all combine to commend it.— 
Boston Medical and Surgical Journal, May 10, 1888. 



Holmes' Treatise on Surgery.— One Volume. 

A Treatise on Surgery ; Its Principles and Practice. By Timothy 
Holmes, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. 
From the fifth English edition, edited by T. Pickering Pick, F. E. C. S. In one 
octavo volume of 997 pages, with 428 illustrations. Cloth, $6.00 ; leather, $7.00. 



To the younger members of the profession and 
to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well- written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the surgeon's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient. — Pacific 
Medical Journal, July, 1889. 



Hamilton on Fractures and Dislocations.— Eighth Edition. 

A Practical Treatise on Fractures and Dislocations. By Frank 
H. Hamilton, M. D., LL. D., Surgeon to Belle vne Hospital, New York. New (8th) edi- 
tion, revised and edited by Stephen Smith, M. D., Prof, of Clinical Surgery in Univ. ot 
City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50 ; leather, $6.50. 



Its numerous editions are convincing proof if any 
is needed, of its value and popularity. It is pre- 
eminently the authority on fractures and disloca- 
tions, and universally quoted as such. In the new 
edition it has lost none of its former worth. The 
additions it has received by its recent revision make 
it a work thoroughly in accordance with modern 
practice, theoretically, mechanica'ly, aseptically. 
The task of writing a complete treatise on a sub- 
ject of such magnitude is no easy one. Dr. Smith 



has aimed to make the present volume a correct 
exponent of our knowledge of this department 
of surgery. In examining the volume one is at 
once struck with the evidence of the vast amount 
of labor its compilation and reconstruction must 
have necessitated. The more one reads the more 
one is impressed with its completeness. The work 
has been accomplished, and has been done clearly, 
concisely, excellently well.— Boston Medical and 
Surgical Journal, May 26, 1892. 



Stimson's Operative Surgery.— Second Edition. 

A Manual of Operative Surgery. By Lewis A. Stimson, B. A., M. D., 

Professor of Clinical Surgery in the University of the City of New York. Second edi- 
tion. In one royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 

The author knows the difficult art of condensa- 
tion. Thus the manual serves as a work of 
reference, and at the same time as a handy 
guide. It teaches what it professes, the steps 
of operations. In this edition Dr. Stimson has 
sought to indicate the changes that have been 
effected in operative methods and procedures by 



the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



Stimson on Fractures and Dislocations. 

A Treatise on Eractures and Dislocations. By Lewis A. Stimson, 
M. D. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 illustra- 
tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, 
cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. 

The appearance of the second volume marks the exhibits the surgery of Dislocations as it is taught 
completion of the author's original plan of prepar- and practised by the most eminent surgeons of the 
ing a work which should present in the fullest present time. Containing the results of such ex- 
manner all that is known on the cognate subjects tended researches it must for a long time be re- 
of Fractures and Dislocations. The volume on garded as an authority on all subjects pertaining 
Fractures assumed at once the position of authority to dislocations. Every practitioner of surgery will 
on the subject, and its companion on Dislocations feel it incumbent on him to have it for constant 
will no doubt be similarly received. This volume | reference. — Cincinnati Medical News, May, 1888. 



Pick on Fractures and Dislocations. 

Fractures and Dislocations. By T. Pickering Pick, F. B. C. S., Sur- 
geon to and Lecturer on Surgery at St. George's Hospital, London, 
of 530 pp., with 93 illus. Limp cloth, $2.00, 



In one 12mo. vol. 
See Series of Clinical Manuals, page 30. 



Marsh on the Joints. 

Diseases of the Joints. By Howard Marsh, F. E. C. S., Senior Assistant 
Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 468 pages, with 
64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Ophthalmology, Otology. 23 

Norris & Oliver's Ophthalmology.— Just Ready. 

A Text-Book of Ophthalmology. By William F. Norris, M. D., 
Professor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, 
M. D., Surgeon to Wills' Eye Hospital, Philadelphia. In one very handsome octavo 
vol. of 641 pages, with 357 engravings and 5 colored plates. Cloth, §5 ; leather, $6. 

The preparation of this magnificent work has engaged its eminent authors during 
a period exceeding seven years, their effort being to produce a guide for the student and 
practitioner which should represent the most advanced state of its science in the clearest 
possible manner. The volume embodies not only the results of large personal experience, 
but also of most extensive acquaintance with the vast and rich literature of its department. 
By a careful selection of material and the employment of a terse style the authors have 
secured the advantages of clearness and comprehensiveness in a volume of convenient size. 
The series of illustrations is singularly rich and is thoroughly in keeping with the 
literary material which it embellishes. The volume is assured of the foremost position 
as a text-book and work of reference. 

Berry on the Eye.— New Edition. Just Ready. 

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. 
By George A. Berry, M. B., F. E. C. S., Ed., Ophthalmic Surgeon, Edinburgh Eoyal 
Infirmary. New (second) edition. In one octavo volume of 750 pages, with 197 illustra- 
tions, mostly lithographic. Cloth, $8.00. 

The thorough revision of Berry's book has re- 1 close connection with the matter to which they 
suited in a volume largely increased in text and I relate — an obvious point of convenience for the 
illustrations, and the practical character has been ! reader. It is an admirable book and will hence- 
maintained. The work is distinguished by its - forth occupy and hold its place as one of the best 
profusion of beautifully colored illustrations which treatises upon the subject we have. — Annals of 
are scattered throughout the text and placed in | Ophthalmology and Otology, July, 1893. 

Juler's Ophthalmic Science and Practice. 

A Handbook of Ophthalmic Science and Practice. By Henry E. 
Juler, F. E. C. S., Senior Assistant Surgeon, Eoyal Westminster Ophthalmic Hospital; 
Late Clinical Assistant, Moorfields, London. English edition. Handsome 8vo. volume 
of 442 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of Jaeger 
and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50 ; leather, $6.50. 

ject of ophthalmology. We would especially refer 
our readers to the chapter on the refraction of the 
eye, a subject of essential importance in the diag- 
nosis and treatment of optical errors. We confi- 
dently anticipate a most cordial welcome for this 
work alike by students and practitioners of medi- 
cine. — The Practitioner, July, 1893. 



The second edition of Mr. Juler's work has, we 
know, been anxiously awaited. The author has 
made numerous alterations and additions, alike in 
the text and in the illustrations, so that the reader 
is provided in a readable form, and with a concise- 
ness thoroughly compatible with accuracy of de- 
scription, with all that is most modern on the sub- 



Field's Manual of Diseases of the Ear.— Just Ready. 

A Manual of Diseases of the Ear. By George P. Field, M. E. C. S., 

Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, 

London. In one octavo of 391 pp., with 73 engravings and 21 colored plates. Cloth, $3.75. 

This book is written by an authority on this I book for the student, and a safe and reliable guide 

subject, and may be recommended as a good text- | for the practitioner. — Edinburgh Med. Jowr.,May '93. 

Burnett on the Ear.— Second Edition. 

The Bar, Its Anatomy, Physiology and Diseases. A Practical 
Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, 
A. M., M. D., Professor of Otology in the Philadelphia Polyclinic ; President of the 
American Otological Society. Second edition. In one handsome octavo volume of 580 
pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

Politzer's Text-Book of DiseasesN)f the Ear.— New Ed. In Press 

A Text-Book of the Diseases of the Ear and Adjacent Organs. 
By Dr. Adam Politzer, Imperial-Royal Professor of Aural Therapeutics in the Uni- 
versity of Vienna. In one large cctavo vol. of about 800 pages, with about 300 engravings. 

Nettleship on the Eye.— Fifth Edition. 

Diseases of the Eye. By Edward Nettleship, F. E. C. S., Ophthalmic 
Surgeon at St. Thomas' Hospital, London. Surgeon to the Eoyal London (Moorfields) 
Ophthalmic Hospital. Fourth American from the fifth English edition, thor- 
oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College, 
Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from 
Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. 



This is a well-known and a valuable work. It 
was primarily intended for the use of students, 
and supplies their needs admirably, but it is as 
useful for the practitioner, or indeed more so. It 
does not presuppose the large amount of recondite 



knowledge to be present which seems to be as- 
sumed in some of our larger works, is not tedious 
from over-conciseness, and yet covers the more 
important parts of clinical ophthalmology.— New 
York Medical Journal, December 13, 1890. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 

• 



24 Urinary & Renal Dis., Dentistry, Ophthal. 
Roberts on Urinary and Renal Diseases.— Fourth Edition. 

A Practical Treatise on Urinary and Renal Diseases, including 
Urinary Deposits. By Sir William Boberts, M.D., Lecturer on Medicine in the 
Manchester School of Medicine, etc. Fourth American from the fourth London edi- 
tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

It may be said to be the best book in print on the 
subject of which it treats. — The American Journal 
of the Medical Sciences, Jan. 1886. 

It is an unrivalled exposition of everything 



which relates directly or indirectly to the diagno- 
sis, prognosis and treatment of urinary diseases, 



and possesses a completeness not found else- 
where in our language in its account of the differ- 
ent affections.— Manchester Med. Chron., July, '85. 
The value of this treatise as a guide book to the 
physician in daily practice can hardly be over- 
estimated. — Medical, Record, July 31, 1886. 



Purdy on Brighfs Disease and Allied Affections. 

Bright's Disease and Allied Affections of the Kidneys. By 

Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases in the Chi- 
cago Polyclinic. In one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ;" and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 
1886. 



Morris on Surgical Diseases of the Kidney. 

Surgical Diseases of the Kidney. By Henry Morris, F. E. C. S., 
Surgeon to Middlesex Hospital, London. 12mo., 554 pages, with 40 woodcuts, and 
6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 30. 

Thompson on the Urinary Organs. 

Lectures on Diseases of the Urinary Organs. By Sir Henry 

Thompson, Professor of Clinical Surgery to University College Hospital, London. 
Second American from the third English edition. Octavo, 203 pp., 25 illus. Cloth, $2.25. 

Thompson on the Pathology and Treatment of Stricture of the 
Urethra and Urinary Fistulse. From the third English edition. In one octavo 
volume of 359 pages, with 47 engravings and 3 plates. Cloth, $3.50. 

The American System of Dentistry. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M.D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. For sale by subscription only. 
As an encyclopaedia of Dentistry it has no su- 

fierior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
greatest value to all engaged in the practice of 
dentistry. — American Jour. Dent. Set., Sept. 1886. 

A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it. — Odonto- 
graphy Journal, Jan. 1887. 



Coleman's Dental Surgery.— American Edition. 

A Manual of Dental Surgery and Pathology. By Alfred Coleman 
L. E. C. P., F. E. C. S., Exam. L. D. S., Lecturer on Dental Surgery at St. Bartholomew's 
Hospital, London. Thoroughly revised and adapted to the use of American Students, by 
by Thomas C. Stellwagen, M. A., M. I*, D. D. S., Prof, of Physiology in the Philadel- 
phia Dental College. Octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

Carter & Frost's Ophthalmic Surgery. 

Ophthalmic Surgery. By E. Brudenell Carter, F. E. C. S., Lecturer 
on Ophthalmic Surgery at St. George's Hospital, London, and W. Adams Frost, F. E C. S., 
Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London. In one 12mo. 
volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appen- 
dix of formula?. Cloth, $2.25. See Series of Clinical Manuals, page 30. 



BASHAM ON RENAL DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. In 
one 12mo. vol. of 304 pages, with 21 illustrations. 
Cloth, $2.00. 

WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 



titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 

LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Impotence, Sterility, Venereal, Skin. 



25 



Fourth Edition. 



Gross on Impotence, Sterility, etc 

A Practical Treatise on Impotence, Sterility, and Allied Dis- 
orders of the Male Sexual Organs. By Samuel W. Gross, A. M., M. D. f 
LL. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson 
Medical College of Philadelphia. Fourth edition, thoroughly revised by F. K. Sturgis, 
M. D., Prof, of Diseases of the Genito-Urinarv Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one 8vo. vol. of 165 pages, with 18 illus. Cloth, $1.50. 

rhoea, and prostatorrhcea. The book is a practical 
one and in addition to the scientific and very in- 
teresting discussions on etiology, symptoms, etc., 
there are lines of treatment laid down that an 



Three editions of Professor Gross' valuable book 
have been exhausted, and still the demand is 
unsupplied. Dr. Sturgis ha9 revised and added 
to the previous editions, and the new one appears 
more complete and more valuable than before. 
Four important and generally misunderstood sub- 
jects are treated— impotence, sterility, s^permator- 



ith 



practitioner can follow and which have met 
success in the hands of author and editor.— Medi- 
cal Record, Feb. 25, 1891. 



Taylor on Venereal Diseases.— Sixth Edition. Preparing. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. By Robert W. Taylor, A. M., M. D., 
Clinical Professor of Genito- Urinary Diseases in the College of Physicians and Surgeons, 
New York. Being the sixth edition of JBumsteod and Taylor, rewritten by Dr. Taylor. 
Large 8vo. volume, about 900 pages, with about 150 engravings, as well as numerous 
chromo-lithographs. In active preparation. A notice of the previous edition is appended. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 



upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — Am. Jour, of the Med. Sciences, Jan. 1884. 



Culver & Hayden's Manual of Venereal Diseases. 

A Manual of Venereal Diseases. By Everett M. Culver, M. D. 
Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James 
E. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- 
geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75. 

venereal diseases for the general practitioner to 
adopt as a guide. The general practitioner needs 
a few simple, concise and clearly presented laws,, 
in the execution of which he cannot fail either to 
cure or prevent the ravages of the maladies in 
question and their direful results. — Buffalo Medical 



This book is a practical treatise, presenting in a 
condensed form the essential features of our pres- 
ent knowledge of the three venereal diseases, 
syphilis, chancroid and gonorrhea. We have ex- 
amined this work carefully and have come to the 
conclusion that it is the most concise, direct and 
able treatise that has appeared on the subject of 



and Surgical Journal, May, 1892. 



Cornil on Syphilis. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. 

Cornil, Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hos- 
pital. Specially revised by the Author, and translated with notes and additions by J. 
Henry C. Simes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa., 
and J. William White, M. D., Lecturer on Venereal, Diseases, Univ. of Pa. In one 
handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 
The anatomy, the histology, the pathology and perusal without the feeling that his grasp of the 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



wide and important subject on which it treats is 
a stronger and surer one.— The London Practi- 
tioner, Jan. 1882. 



Hutchinson on Syphilis. 

Syphilis. By Jonathan Hutchinson, F. E. S., F. K. C. S., Consulting Sur- 
geon to the London Hospital. In one 12mo. volume of 542 pages, with 8 chromo- 
lithographs. Cloth, $2.25. See Series of Clinical Manuals, page 30. 

Those who have seen most of the disease and I facts and suggestions which abound in these 
those who have felt the real difficulties of diagno- pages.— London Medical Record, Nov. 12, 1887. 
sis and treatment will most highly appreciate the | 



Gross on the Urinary Organs. 



A Practical Treatise on the Diseases, Injuries and Malforma- 
tions of the Urinary Bladder, the Prostate Gland and the Urethra. 
By Samuel D. Gross, M. D., LL. L\, D. C. L. etc. Third edition, thoroughly revised 
by Samuel W. Gross, M. D. In one octavo vol. of 574 pp., with 170 illus. Cloth, $4.50. 



FOX'S EPITOME OF SKIN DISEASES. WITH 
FORMULAE. Third edition, revised and en- 
larged. In one 12mo. vol. of 238 pp. Cloth, $1.25. 

HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, 
with plates. Cloth, $2.25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 



LEE'S LECTURES ON SVPHILTS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING 
THE ORGANS OF GENERATION. In one 
Rvo. volume of ?4fi pages. Cloth. $2.25. 

WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE AND DISEASES OF THE SKIN. 
In one handsome small octavo volume of 535 
pages. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



26 



Venereal and Skin Diseases. 



Taylor's Clinical Atlas of Venereal and Skin Diseases. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diag- 
nosis, Prognosis and Treatment. By Kobeet W. Taylor, A. M., M. D., Clinical Pro- 
fessor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York ; 
In eight large folio parts, and comprising 58 beautifully colored plates with 213 figures, 
and 431 pages of text with 85 engravings. Price per part, $2.50. Bound in one volume, 
half Eussia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 
It would be hard to use words which would per- I student can examine these true-to-life chromo-lith 



spicuously enough convey to the reader the great 
value of this Clinical Atlas. This Atlas is more 
complete even than an ordinary course of clinical 
lectures, for in no one college or hospital course 
is it at all probable that all of the diseases herein 
represented would be seen. It is also more ser- 
viceable to the majority of students than attend- 
ance upon clinical lectures, for most of the 
students who sit on remote seats in the lecture 
hall cannot see the subject as well as the office 



ographs. Comparing the text to a lecturer, it is 
more satisfactory in exactness and fullness than 
he would be likely to be in lecturing over a single 
case. Indeed, this Atlas is invaluable to the gen- 
eral practitioner, for it enables the eye of the 
physician to make diagnosis of a given case of 
skin manifestation by comparing the case with 
the picture in the Atlas, where will be found also 
the text of diagnosis, pathology, and full sections 
on treatment.— Virginia Medical Monthly, Dec. 1889. 



Jackson's Ready-Reference Handbook of Skin Diseases. 

The Ready-Reference Handbook of Diseases of the Skin. By 

George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College 



of the New York Infirmary. In one 12mo. volume of 544 pages, with 50 illustrations 
and a colored plate. Cloth, $2.75. 

Intended to serve as a reference book for the 
general practitioner, "no attempt has been made 
to discuss debatable questions," and "hence pa- 
thology and etiology do not receive as full consid- 
eration as symptomatology, diagnosis and treat- 
ment." The alphabetical arrangement of diseases, 
so universal now in books of this class, has been 
followed by Dr. Jackson. After a short and con- 
densed account of the anatomy and physiology of 



the skin, the author presents a few notes of com- 
mon and practical importance on diagnosis and 
therapeutics, which are followed by his well- 
known and graphic dermatological " Don'ts." 
Part II. treats in alphabetical order of the dis- 
eases of the skin and their management. This 
hook seems to us the best of its class that has 
yet appeared. — Boston Medical and Surgical Jour- 
nal, May 18, 1893. 



Pye-Smith on Diseases of the Skin.— Just Ready. 

A Handbook of Diseases of the Skin. By P. H. Pye-Smith, M. D., 
F. R. S, Physician to Guy's Hospital, London. In one octavo volume of 407 pages, 
with 26 illustrations, 18 of which are colored. Cloth, $2.00 

It is a plain, practical treatise on dermatology, 



written for the student and general practitioner 
by a general practitioner of broad experience in 
the special subject of which he writes. He simpli- 
fies the nomenclature, and succeeds in removing 
much of the difficulty. After reviewing the recent 



advances made in this department of medicine, 
he pays a merited compliment to the "important 
contributions made by the newest school of 
dermatology, that of America." — Pittsburg Medical 
Recwd, June, 1893. 



Hardaway's Manual of Skin Diseases. 

Manual of Skin Diseases. With Special Reference to Diagnosis and Treat- 
ment. For the use of Students and General Practitioners. By W. A. Hardaway, M. D., 
Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. 
Dr. Hardaway's large experience as a teacher | embraces all essential points connected with the 
and writer has admirably fitted him for the diffi- 
cult task of preparing a book which, while suffi- 
ciently elementary for the student is yet suffi- 
ciently thorough and comprehensive to s-erve as a 
book of reference for the general practitioner. It 



diagnosis and treatment of diseases of the skin, 
and we have no hesitation in commending it as 
the best manual that has yet appeared in this 
department of Medicine.— Journal of Cutaneous 
and Genito- Urinary Diseases. 



Hyde on the Skin.— Third Edition. Just Ready. 

A Practical Treatise on Diseases of the Skin. For the use of Students 
and Practitioners. By J. Kevins Hyde, A. M., M. D., Professor of Dermatology and Ven- 
ereal Diseases in Push Medical College, Chicago. Third edition. In one octavo volume 
of 802 pages, with 9 colored plates and 10S illustrations. 
A notice of the previous edition is appended. 

The prescriptions and formulae are given in both 



His treatise is like his clinical instruction, 
admirably arranged, attractive in diction, and 
strikingly practical throughout. No clearer de- 
scription of the various primary and consecutive 
lesions of the skin is to be met with anywhere. 



common and metric systems. Altogether it is a 
work exactly fitted to the needs of a general prac- 
titioner, and no one will make a mistake in pur- 
chasing it.— Med. Press of Western N. F., June, 1888. 



Jamieson on Diseases of the Skin.— Third Edition. 

Diseases of the Skin. A Manual for Students and Practitioners. By 
W. Allan Jamieson, M. D., Lecturer on Diseases of the Skin, School of Medicine, Edin- 
burgh. Third edition, revised and enlarged. In one octavo volume of 656 pages, with 
woodcut and 9 double-page chromo- lithographic illustrations. Cloth, $6.00. 
The first edition of this work appeared in 1888 



and the following year a second. The scope of the 
work is essentially clinical, little reference being 
made to pathology or disputed theories. Almost 
every subject is followed by illustrative cases 
taken from the author's practice, and the reader 
is constantly reminded that he has before him a 



record of personal experience. The pages are 
filled with interest to all thos<> occupied with skin 
diseases. The general practitioner will find the 
book of great value in matters of diagnosis and 
treatment. The latter is quite up to date, and the 
formulae have been selected with care.— Medical 
Record, April 9, 1802. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Diseases of Women 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 



These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor pre- 
sents a monograph upon his special topic, so that 
everything in the way of history, theory, methods, 
and results is presented to our fullest need. As a 
work of general reference, it will be found remarka- 
bly full and instructive in every direction of 
inquiry.— The Obstetric Gazette, September, 1889. 

One is at a loss to know what to say of this vol- 
ume, for fear that just and merited praise may be 
mistaken for flattery. The papers of Drs. Engel- 
mann, Martin, Hirst, Jaggard and Reeve are incom- 
parably beyond anything that can be found in 
obstetrical works. — Journal of the American Medical 
Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 



United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors." 
It, like the other, has been written exclusively 
by American physicians who are acquainted with 
all the characteristics of American people, who are 
well informed in regard to the peculiarities of 
American women, their manners, customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy- 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing. — 
Cincinnati Med. News, July, 1887. 



Emmet's Gynaecology.— Third Edition. 

The Principles and Practice of Gynecology ; For the use of Students 
and Practitioners of Medicine. By Thomas Addis Emmet, M. D., LL. T>., Surgeon to 
the Woman's Hospital, New York, etc. Third edition, thoroughly revised. In one 
large and very handsome 8vo. vol. of 880 pp., with 150 illus. Cloth, $5 ; leather, $6. 

We are in doubt whether to congratulate the [ the privilege thus offered them of perusing the 
author more than the profession upon the appear- j views and practice of the author. His earnestness 
ance of the third edition of this well-known work, j of purpose and conscientiousness are manifest. 
Embodying, as it does, the life-long experience of j He gives not only his individual experience but 
one who has conspicuously distinguished himself i endeavors to represent the actual state of gynse- 
as a bold and successful operator, and who has cological science and art. — British Medical Jour- 
devoted so much attention to the' specialty, we | nal, May 16, 1885. 
feel sure the profession will not fail to appreciate j 



Tait's Diseases of Women and Abdominal Surgery. 

Diseases of Women and Abdominal Surgery. By Lawson Tait, 
F. R. C. S., Professor of Gynaecology in Queen's College, Birmingham, late President of 
the British Gynecological Society, Fellow American Gynaecological Society. In two 
octavo vols. Vol. I., 554 pp., 62 engravings and 3 plates. Cloth, $3. Vol. II., preparing. 
The plan of the work does not indicate the regu- Much of the text is abundantly illustrated <vith 
lar system of a text book, and yet nearly every- eases, which add value in showing the results of 
thing of disease pertaining to the various organs the suggested plans of treatment. We feel con- 
receives a fair consideration. The description of fident that few gynecologists of the country will 
diseased conditions is exceedingly clear, and the j fail to place the work in their libraries.— The 
treatment, medical or surgical, is very satisfactory, j Obstetric Gazette, March, 1890. 



Edis on Diseases of Women. 

The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. By Arthur W. 
Edis, M. D., Lond., F. K. C. P., M. E. C. S., Assistant Obstetric Physician to Middlesex 
Hospital, late Physician to British Lying-in-Hospital. In one handsome octavo volume 
of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 



The special qualities which are conspicuous 
are thoroughness in covering the whole ground, 
clearness of description and conciseness of state- 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages.— Boston 
Med. and Surg. Journ., March 2, 1882. 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Including Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $±.50. 



WEST'S LECTURES ON THE DISEASES OF 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, $4.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



28 



Diseases of Women — (Continued). 



Tliomas & Munde' on Diseases of Women.— Sixth Edition. 

A Practical Treatise on the Diseases of Women. By T. Gaillakd 
Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of 
Physicians and Surgeons, New York, and Paul F. Munde, M.D., Professor of Gynecol- 
ogy in the New York Polyclinic. New (sixth) edition, thoroughly revised and rewritten 
by Db,. Munde. In one large and handsome octavo volume of 824 pages, with 347 
illustrations, of which 201 are new. Cloth, $5.00 ; leather, $6.00. 



Probably no treatise ever written by an Ameri- 
can author on a medical topic has been accepted 
by more '.practitioners, as a standard text-book, or 
read with pleasure and profit by more medical 
students than Thomas on the diseases of women. 
Next to the indescribable charm of listening to 
Dr. Thomas' lectures and clinics, which have in 
them the element of a captivating and inspiring 
personality— which must be heard and felt to be 
properly appreciated— is this volume, which in 
classic excellence, elegance of diction and scholar- 



ly and scientific statement must remain what it 
long has been, a standard text-book both for prac- 
titioner and student, at home and abroad, and an 
enduring pride to American gynecologists. In a 
field by no means new or wanting in honorable 
achievement, Dr. Munde has added to his already 
enviable reputation by the manner in which he 
has acquitted himself in an undertaking at once 
so delicate and difficult and for which he will 
receive, at the hands of the profession, their ac- 
knowledgment. — The Brooklyn Med. Jour., Mar. '92. 



Sutton on tlie Ovaries and Fallopian Tubes. 

Surgical Diseases of the Ovaries and Fallopian Tubes, including 
Tubal Pregnancy. By J. Bland Sutton, F. E. C. S., Assistant Surgeon to the 
Middlesex Hospital, London. In one crown octavo volume of 544 pages, with 119 
engravings and 5 colored plates. Cloth, $3.00. 

that the writer has to say is stated in a clear, 



To gynecologists the name of Mr. Sutton has 
long been familiar as that of a conscientious 
worker in pelvic pathology, as well as a compara- 
tive anatomist of wide reputation. The present 
volume contains the substance of valuable papers 
which have been scattered throughout journals 
and society reports during the past five or six 
years, and deserves the careful attention of gen- 
eral readers as well as of specialists. Everything 



practical way. The author's style is singularly 
concise — almost epigrammatic. Statements which 
in a less weighty authority might-appear too dog- 
matic gather force by the positive manner in 
which they are made. We have no hesitation in 
pronouncing it the best monograph of the kind 
which has yet appeared. — Medical Record, New 
York, May 21, 1892. 



Davenport's Non-Surgical Gynaecology.— Second Edition. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. 

Designed especially for the Use of Students and General Practitioners. By Francis 
H. Davenport, M. D., Assistant in Gynaecology in the Medical Department of Harvard 
University, Boston. New (second) edition. In one handsome 12mo. volume of 314 
pages, with 107 illustrations. Cloth, $1.75. 



The first edition of Dr. Davenport's book, which 
was published three years ago, evidently met with 
the reception it deserved, or the second edition 
would not have followed so soon. The title is an 
attractive one, and the contents are of value to the 
student and general practitioner. One advantage 
of it is that it teaches the physician or the student 
how to do the little things, or to remedy the 
minor evils in connection with gynaecology. In 
these days, when major gynaecology is so largely 



practised, minor gynaecology is too frequently 
ignored. To those in the profession who are 
about to interest themselves particularly in this 
branch of surgery, and to the student who in the 
future intends to make gynaecology his life-work, 
we believe that Davenport's book will be essential 
to his success, because it will teach him facts 
which larger works sometimes ignore. — The Thera- 
peutic Gazette, October 15, 1892. 



May- 



's Manual of Diseases of Women.— Second Edition. 

A Manual of theDiseases of Women. Being a concise and systematic 
exposition of the theory and practice of gynecology. By Charles H. May, M. D., 
late House Surgeon to Mount Sinai Hospital, New York. Second edition, edited by 
L. S. Batj, M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. 
volume of 360 pages, with 31 illustrations. Cloth, $1.75. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily. — The Physician and 
Surgeon, June, 1890. 



Duncan on Diseases of Women. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint 
Bartholomew's Hospital. By J. Matthews Duncan, M. D., LL. D., F. B. S. E., etc. 
In one octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the textrbooks ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



stamp of individuality that they deserve to be 
widely read.— N. Y. Medical Journal, March, 1880. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 



American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Obstetrics, 



29 



Parvin's Science and Art of Obstetrics.— Second Edition. 

The Science and Art of Obstetrics. By Theophilus Parvin, M. D., 
LL. D., Professor of Obstetrics and the Diseases of Women and Children in Jefferson 
Medical College, Philadelphia. Second edition. In one handsome 8vo. volume of 701 
pages, with 239 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. 

scholar and a master. Earely in the range of 



The second edition of this work is fully up to the 
present state of advancement of the obstetric art. 
The author has succeeded exceedingly well in 
incorporating new matter without apparently in- 
creasing the size of his work or interfering with 
the smoothness and grace of its literary construc- 
tion. He is very felicitous in his descriptions of 
conditions, and proves himself in this respect a 



obstetric literature can be found a work which is 
so comprehensive and yet compact and practical. 
In such respect it is essentially a text book of the 
first merit. The treatment of the subjects gives a 
real value to the work — the individualities of a 
practical teacher, a skilful obstetrician, a close 
thinker and a ripe scholar. — Med. Rec, Jan. 17, '91 



Playfair's Midwifery.— Eighth Edition. Just Ready. 

A Treatise on the Science and Practice of Midwifery. By W. S. 

Playfair, M. D., F. E. C. P., Professor of Obstetric Medicine in King's College, Lon- 
don. Sixth American, from the eighth English edition. Edited, with additions, by 
Eobert P. Harris, M. D. In one handsome octavo volume of 697 pages, with 217 
engravings and 5 plates. Cloth, $4 00 ; leather, $5.00. 
A notice of the previous edition is appended. 



Truly a wonderful book; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 
is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- 



tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations, 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice, 
and also of all the coincident troubles connected 
therewith.— Southern Practitioner, Dec. 1S89. 



King's Manual of Obstetrics.— Fifth Edition. ' 

A Manual of Obstetrics. By A. F. A. King, M. D., Professor of Obstetrics 
and Diseases of Women in the Medical Department of the Columbian University, Wash- 
ington, D. C. ; and in the University of Vermont, etc. New (fifth) edition. In one 12mo. 
volume of 446 pages, with 150 illustrations. Cloth, $2.50. 



So comprehensive a treatise could not be brought 
within the limits of a book of this size were not 
two things especially true. First, Dr. King is a 
teacher of many years' experience, and knows 
just how to present his subjects in a manner for 
them to be best received; and, secondly, he can 
put his ideas in a clear and concise form. In 
other words, he knows how to use the English 
language. He gives us the plain truth, free from 



unnecessary ornamentation. Therefore we say 
there are nine hundred pages of matter between 
the covers of this manual of four hundred and 
fifty pages. We cannot imagine a better manual 
for the hard- worked student; while its clear and 
practical teachings make it invaluable to the busy 
practitioner. The illustrations add much to the 
subject matter.— The National Medical Review, 
October, 1892. 



Barnes' System of Obstetric Medicine and Surgery. 

A System of Obstetric Medicine and Surgery, Theoretical and 
Clinical. For the Student and the Practitioner. By Eobert Barnes, M. D., Phys- 
ician to the General Lying-in Hospital, London, and Fancourt Barnes, M. L>., Obstetric 
Physician to St. Thomas' Hospital, London. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5; leather, $6. 

It is not an exaggeration to say of the book that 
it is the best treatise in the English language yet 
published. Every practitioner who desires to have 
the best obstetrical opinions of the time in a 



readily accessible and condensed form, ought to 
own a copy of the book. — Journal of the American 
Medical Association, June 12, 1886. 



Landis on Labor and the Lying-in Period. 

The Management of Labor, and of the Lying-in Period. 

By Henry G. Landis, A. M., M. D., Professor of Obstetrics and the Diseases of* Women 
in Starling Medical College, Columbus, Ohio. In one handsome 12mo. volume of 334 
pages, with 28 illustrations. Cloth, $1.75. 



LEISHMAN'S SYSTEM OF MIDWIFERY, IN- 
CLUDING THE DISEASES OF PREGNANCY 
AND THE PUERPERAL STATE. Fourth edi- 
tion. Octavo. 

PARRY ON EXTRA-UTERINE PREGNANCY: 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pages. Cloth, $2.50. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V.Keating, M. D., Professor of Obstetrics, 
etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 



octavo volume of 640 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, $7. 

CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, 82.60. 

TANNER ON PREGNANCY. Octavo, 490 pages, 
colored plates, 16 cuts. Cloth, $4.25 

WINCKEL'S COMPLETE TREATISE ON THE 
PATHOLOGY AND TREATMENT OF CHILD- 
BED. For Students and Practitioners. Trans- 
lated from the second German edition, by J. R. 
Chad wick, M. D. Octavo 484 pages. Cloth $4.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



30 Dis. of Children, Obstetrics — (Cont'd), Manuals, 



Smith on Children.— Seventh Edition. 

A Treatise on the Diseases of Infancy and Childhood. By 

J. Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital 
Medical College, New York. New (seventh) edition, thoroughly revised and rewritten. 
In one handsome octavo volume of 881 pages, with 51 illus. Cloth, $4.50 ; leather, $5.50. 

We have always considered Dr. Smith's book as 
one of the very best on the subject. It has always 
been practical— a field book, theoretical where 
theory has been deduced from practical experi 



ence. He takes his theory from the bedside and 
the pathological laboratory. The very practical 
character of this book has always appealed to us. 
It is characteristic of Dr. Smith in all his writings 
to collect whatever recommendations are found in 
medical literature, and his search has been wide. 
One seldom fails to find here a practical suggestion 
after search in other works has been in vain. In 
the seventh edition we note a variety of changes 
in accordance with the progress of the times. It 
still stands foremost as the American text-book. 
The literary style could not be excelled, its advice 



is always conservative and thorough, and the 
evidence of research has long since placed its 
author in the front rank of medical teachers. — 
The American Journal of the Medical Sciences, Dec. 
1891. 

In the present edition we notice that many of 
the chapters have been entirely rewritten. Full 
notice is taken of all the recent advances that 
have been made. Many diseases not previously 
treated of have received special chapters. The 
work is a very practical one. Especial care has 
been taken that the directions for treatment shall 
be particular and full. In no other work are such 
careful instructions given in the details of infant 
hygiene and the artificial feeding of infants. — 
Montreal Medical Journal, Feb. 1891. 



Herman's First Lines in Midwifery. 

First Lines in Midwifery: a Guide to Attendance on Natural 
Labor for Medical Students and Midwives. By G. Ernest Herman, M. B., 
F. B.C. P., Obstetric Physician to the London Hospital. In one 12mo. volume of 198 
pages, with 80 illustrations. Cloth, $1.25. See Student's Series of Manuals, below. 



This is a little book, intended for the medical 
student and the educated midwife. The work 
is written in a plain, simple style, and is as 
much as possible devoid of technical terms. It 



will prove valuable to the beginner in midwifery 
and could be read with advantage by the majority 
of practitioners, old and young.— The Medical 
Fortnightly, April 15, 1892. 



Owen on Surgical Diseases of Children. 

Surgical Diseases of Children. By Edmund Owen, M. B., F. K. C. S., 
Surgeon to the Children's Hospital, Great Ormond Street, London. In one 12mo. vol- 
ume of 525 pages, with 4 chromo-lithographic plates and 85 woodcuts. Cloth, $2.00. 
See Series of Clinical Manuals, below. 

One is immediately struck on reading this book honestly recommended to both students and 
with its agreeable style and the evidence it every- practitioners. It is full of sound information, 
where presents of the practical familiarity of its pleasantly given.— Annals of Surgery, May, 1886. 
author with his subject. The book may be 



Student's Series of Manuals. 



A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Luff's Manual of Chem- 
istry,^; Herman's Fhst Lines in Midwifery, $1.25; Treves' Manual of Surgery, by various writers, in 
three volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2; Gould's Surgical 
Diagnosis, $2; Robertson's Physiological Physics, $2; Bruce's Materia Medica and Therapeutics (5th edi- 
tion), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's Dissectors' Man- 
ual, $1.50 ; Ealfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical 
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75. The following is in press: 
Pepper's Forensic Medicine. For separate notices see index on last page. 

Series of Clinical Manuals. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes contain about 550 pages and are freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Broadbent on 
the Pulse, $1.75; Carter* Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Marsh 
on the Joints, $2; Owen on Surgical Diseases of Children, $2; Morris on Surgical Diseases of the 
Kidney, $2.25; Pick on Fractures' and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intesti- 
nal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. The following is in preparation: 
Lucas on Diseases of the Urethra. For separate notices see index on last page. 

Hartsfaorne's Conspectus of the Medical Sciences. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anat- 
omy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
By Henry Hartshorne, A. M., M. D., LL. D., lately Professor of Hygiene in the Uni- 
versity of Pennsylvania. Second edition, thoroughly revised and greatly improved. In 
one large royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5.00. 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
77Q naares. Oloto, $=>.25 ; leather, $6.25. 

WEST ON SOME DISORDERS OF THE NERV- 
OUS SYSTEM IN CHILDHOOD. In one small 
12mo. volume of 127 pages. Cioth, $1.00. 

LUDLOW'S MANUAL OF EXAMINATIONS. A 
Manual of Examinations upon Anatomy, Physi- 



ology, Surgery, Practice of Medicine, Obstetrics, 
Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical 
Formulary. By J. L. Ludlow, M. D., Consulting 
Physician to the Philadelphia Hospital, etc. 
Third edition, thoroughly revised, and greatly 
enlarged. In one 12mo. volume of 81G pages, 
with 370 illustrations. Cloth, §3.25; leather, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



fledical Jurisprudence, Historical. 



31 



Taylor's Medical Jurisprudence.— New Edition. Just Ready. 

A Manual of Medical Jurisprudence. By Alfred S. Taylor, M. D., 
Lecturer on Med. Jurisprudence and Chemistry in Guy's Hosp., London. New American 
from the 12th English edition. Thoroughly revised by Clark Bell, Esq., of the New 
York Bar. In one octavo volume of 787 pages, with 56 illus. Cloth, $4.50; leather, $5.50. 



The work before us, which has become a classic, 
is the authority which has been adopted in all the 
English-speaking courts of justice, and this fact 
is due solely to the circumstance that it is a per- 
fectly reliable guide both in the matter of medical 
and legal authority. The last English edition has 
been much enriched by the additions of Dr. Stev- 
enson, a very acute and accurate editor. The 
American editor, Mr. Clark Bell, is peculiarly 
fitted for this task, and he further availed himself 
of the advice not only of eminent medi -al men, 
but of the suggestions made by legal friends. All 
of these circumstances have, combined in such a 
manner as to permit the publishers to present us 
with a work which, in our opinion, is without a 
peer in the English language. To the legal pro- 
fession it is of the greatest value, more especially 
for the purposes of cross-examination and the 
preparation of briefs One of the strong points of 
the book is the numerous citations which abound 
throughout, and which none but a lawyer, per- 



haps, can appreciate to their fullest extent. — The 
St. Louis Mtdical and Surgical Journal, Dec, 1892. 
Taylor's Medical Jurisprudence is an old stand- 
ard. There is no other work upon the subject 
which has been so uniformly recognized or so 
widely quoted and followed by courts in England 
and this country. It would have been impossible 
to select anyone in this country better fitted for 
the task of revision than Mr- Bell. Profiting by 
the labors with which Dr. Stevenson has enriched 
the twelfth English edition, he has, in this 
eleventh American edition, given us a book fully 
abreast with the most recent thought and knowl- 
edge. On the basis of his own researches, of the 
investigations of scientists throughout the world, 
and of the decisions of our own courts, he has in- 
corporated in it a wealth of practical suggestion 
and instructive illustration which cannot fail to 
strengthen the hold it has so long had upon the 
profession.— The Criminal Law Magazine and Re- 
porter, January, 1893. 



By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

Lea's Superstition and Force.— New Edition. Just Ready. 

Superstition and Force: Essays on The Wager of Law, The 
Wager of Battle, The Ordeal and Torture. By Henry Charles Lea, 
LL. IX, New (4th) edition, revised and enlarged. Boyal 12mo., 629 pages. Cloth, $2.75. 



Both abroad and at home the work has been 
accepted as a standard authority, and the author 
has endeavored by a complete revision and con- 
siderable additions to render it more worthy of 
the universal favor which has carried it to a 
fourth edition. The style is severe and simple, 
and yet delights with its elegance and reserved 
strength. Tne known erudition and fidelity of 
the author are guarantees that all possible origi- 
nal sources of information have been not only 
consulted but exhausted. The subject matter is 



handled in such an able and philosophic man- 
ner that to read and study it is a step toward 
liberal education. It is a comfort to read a book 
that is so thorough, well conceived and well done. 
We should like to see it made a text-book in our 
law schools and prescribed course for admission 
to the bar. — Legal Intelligencer, March 3, 1893. 

A work as remarkable for the wealth of histori- 
cal material treated as for the masterly style of 
the exposition.— London Saturday Review, Feb. 25, 
1893. 



By the same Author. 
Chapters from the Religious History of Spain 

of 522 pages. Cloth $2.50. 

The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 
found are here applied to some side-issues of that 
great subject. We have only to say of this volume 



-In one 12mo. volume 



that it worthily complements the author's earlier 
studies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears on every page. — 
London Antiquary, Jan. 1891. 



In one 8vo. volume of 221 



By the same Author. 
The Formulary of the Papal Penitentiary. 

pages, with a frontispiece. Cloth, $2.50. Just Heady. 

By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy— Excommunication— The Early Church and Slavery. Sec- 
ond and revised edition. In one roj al octavo volume of 605 pages. Cloth, $2.50. 



The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it out to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 



makes the work particularly valuable to the student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 
complex or conflicting forces.— Boston Traveller. 



By the Same Author. 
An Historical Sketch of Sacerdotal Celibacy in the Christian 
Church. Second edition, enlarged. In one octavo volume of 685 pages. Cloth, $4.50. 



This subject has recently been treated with very 
great learning and with admirable impartiality by 
an American author, Mr. Henry C. Lea, in his His- 
tory of S iCerdotat Celibacy, which is certainly one 
of the most valuable works that America has pro- 
duced. Since the great history of Dean Milman, 
I know no work in English which has thrown 



more light on the moral condition of the Middle 
Ages, and none which is more fitted to dispel the 
gross illusions concerning that period which posi- 
tive writers and writers of a certain ecclesiastical 
school have conspired to sustain. — Lecky's History 
of European Morals, Chap. V. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



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Abbott's Bacteriology . 

Allen's Anatomy .... 

American Journal of the Medical Sciences 

American Systems of Gynecology and Obstetrics 

American System of Practical Medicine . 

American System of Dentistry 

Asbhurst's Surgery .... 

Ashwell on Diseases of Women 

Attfield's Cbemistry .... 

Barlow's Practice of Medicine 

Barnes' System of Obstetric Medicine 

Bartbolow on Cholera 

Bartholow on Electricity 

Basbam on Renal Diseases . 

Bell's Comparative Anatomy and Pbysiology 

Bellamy's Surgical Anatomy 

Berry on the Eye .... 

Billings' National Medical Dictionary . 

Blandford on Insanity 

Bloxam's Cbemistry .... 

Bristowe's Practice of Medicine 

Broadbent on the Pulse 

Browne on Koch's Kemedy . 

Browne on the Throat, Nose and Ear 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 

Bryant's Practice of Surgery . 

Bumstead and Taylor on Venereal. See Taylor 

Burnett on the Ear .... 

Butlin on the Tongue .... 

Carpenter on the Use and Abuse of Alcohol 

Carpenter's Human Physiology 

Carter & Frost's Ophthalmic Surgery 

Chambers on Diet and Regimen 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem, 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry . . . 

Coats' Pathologv . . 

Cohen's Applied Therapeutics 

Coleman's Dental Surgery . 

Condie on Diseases of Children 

Cornil on Syphilis .... 

Cullerier & Bumstead on Venereal 

Culver & Hayden on Venereal Diseases . 

Dalton on the Circulation 

Dalton's Human Physiology 

Davenport on Diseases of Women . 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

Dungllson's Medical Dictionary 

Edes' Materia Medica and Therapeutics 

Edis on Diseases of Women . • . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology 

Erichsen's System of Surgery 

Farquharson's Therapeutics and Mat. Med. 

Field's Manual of Diseases of the Ear 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Flint on Respiratory Organs 

Flint on the Heart 

Flint's Essays ..... 

Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology . . . . ' 

Fothergill's Handbook of Treatment 

Fownes' Elementary Chemistry . 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages 

Gant's Student's Surgery 

Gibbes' Practical Pathology 

Gould's Surgical Diagnosis . 

Gray on Nervous and Mental Diseases . 

Gray's Anatomy . ... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

Gross System or Surgery 

Habershon on the Abdomen 

Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hardaway on the Skin 

Hare's Practical Therapeutics 

Hare's System of Practical Therapeutics 

Hartshorne's Anatomy and Pbysiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Herman's First Lines in Midwifery 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hirst & Piersol on Human Monstrosities 

Hoblyn's Medical Dictionary 

Hodge on Women 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

Holmes' Principles and Practice of Surgery 

Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever 

Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jackson on the Skin . 

Jamieson on the Skin . . . 

Jones (C. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

King's Manual of Obstetrics . 



15,30 






: 



10. 



Klein's Histology . 18, 

Landis on Labor . . , 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Chapters from Religious History of Spain 

Lea's Formulary of the Papal Penitentiary 

Lea's Sacerdotal Celibacy 

Lea's Studies in Church "History 

Lea's Superstition and Force 

Lee on S3 r philis . . . 

Lehman n*s Chemical Physiology . 

Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Luff's Manual of Chemistry . 

Lyman's Practice of Medicine 

Lyons on Fever ..... 

Maisch's Organic Materia Medica . 

Marsh on the Joints 

May on Diseases of Women . 

Medical News ..... 

Medical News Physicians' Ledger . 

Medical News Visiting List . 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Morris on Diseases of the Kidney . 

Musser's Medical Diagnosis . 

National Dispensatory 

National Medical Dictionary 

Nettleship on Diseases of the Eye . 

Norris and Oliver on the Eye 

Owen on Diseases of Children 

Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery . ... 

Pavy on Digestion and its Disorders 

Payne's General Pathology . 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pepper's System of Medicine 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery . 

Playfair on Nerve Prostration and Hysteria 

Playfair's Midwifery .... 

Politzer on the Ear .... 

Power's Human Physiology . 

Purdyon Bright's Disease and Allied A flections 

Pye-Smith on the Skin 

Quiz Series ..... 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Compend of Anatomy . , 

Roberts' Surgery . 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schofield's Physiology 

Schreiber on Massage .... 

Seiler on the Throat, Nose and Naso-Pharynx 

Senn's Surgical Bacteriology 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery 

Stille on Cholera 

Stille & Maisch's National Dispensatory 

Still6's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 

Students' Quiz Series .... 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Sutton on the Ovaries and Fallopian Tubes 

Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Poisons .... 

Taylor on Venereal Diseases 

Taylor's Medical Jurisprudence 

Thomas & Munde on Diseases of Women 

Thompson on Stricture 

Thompson on Urinary Organs . A 

Todd on Acute Diseases 

Treves' Manual of Surgery . 

Treves on Intestinal Obstruction . 

Treves' Operative Surgery . 

Treves' Student's Handbook of Surg. Operations, 

Treves' Surgical Applied Anatomy . . 6 

Tuke on the Influence of Mind on the Body 

Vaughan & Novy's Ptomaines and Leucomaines 

Visiting List, The Medical News 

Walshe on the Heart . 

Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Wharton's Minor Surgery and Bandaging 

Whitla's Dictionary of Treatment 

Williams on Consumption .... 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy .... 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry 

Year-Books of Treatment for 8fi, '87. '91, '92, '93. 

Yeo's Medical Treatment, or Clinical Therapeutics, 

Yeo on Food in Health and Disease . . 16 

Young's Orthopaedic Surgery 



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